HX641 54734 
RC341  .Ml  7  Functional  disorders 


ervous 


Fjisordersi^Won^ei^ 

«McGillicuddif 


CAL  BOOKSKLLEES, 

)12  'Walnut  Street, 

•HILADKLPHIA.       


Coliimfim  ^nibem'tp 
CoOege  of  ^f^psicmns  anb  burgeons 


^tltvmtt  I.ihvavp 


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FUNCTIONAL  DISORDERS 


OF  THE 


NERVOUS  SYSTEM  IN  WOMEN 


BY 

T.  J.  MCGILLICUDDY,  A.M.,  M.D. 

Consulting  Physician  to  the  Italian  Hospital,  iV.   Y.;   Surgeon-in-charge  of  the  New  York 

Mother's  Home  Maternity  Hospital ;  Surgeon-in-charge  of  the  Metropolitan  Dispensary 

and  Hospital  for  Women  and  Children ;    Fellow  of  the  Neio  York  Academy  of 

Medicine  ;   Member  of  the  American  Medical  Association  ;  Member  of 

the  International  Medical  Congress,  Berlin,  1891,  etc,  etc 


ILLUSTRATED    BY   FORTY-FIVE   WOOD    ENGRAVINGS   AND 
TWO    CHROMO-LITHOGRAPHIC    PLATES 


NEW  YORK 

WILLIAM  WOOD   AND   COMPANY 

1896 


Copyright  by 
WILLIAM     WOOD     &     COMPANY, 


PREFACE. 


The  attention  of  the  profession  has  been  confined  of  late 
years  too  exckisively  to  surgical  gynaecology  and  to  dis- 
eases with  marked  pathological  changes.  Great  strides 
have  been  made  in  the  development  of  these  branches  of 
medical  science.  They  have  had  many  able  exponents. 
Less  has  been  written  on  medical  gynsecology,  although  a 
subject  equally  deserving  of  research  and  one  which  will 
abundantly  reward  the  scientific  investigator.  There  are 
many  important  nervous  disorders  in  women  without  de- 
terminable anatomical  changes  in  either  the  brain  or  spinal 
cord.  Although  there  is  no  interesting  anatomico-patho- 
logical history  to  be  detailed  in  such  cases,  they  are  so  com- 
mon, and  cause  so  much  suffering,  that  we  must  give  them 
the  share  of  attention  they  deserve. 

They  are  not  usually  found  in  hospitals  but  are  seen  fre- 
quently in  private  practice,  and  very  often  in  the  upper 
strata  of  society.  The  observations  which  follow  have  no 
claim  to  completeness  on  the  subject.  It  is  only  intended 
to  draw  the  attention  to  a  class  of  affections  which  is 
frequently  seen,  and  not  so  minutely  described  as  the  im- 
portant organic  diseases  and  surgical  affections. 

In  the  consideration  of  the  functional  derangements  of 
the  nervous  system  in  women,  it  should  be  remembered 
that  many  uterine  and  digestive  disorders  are  simply 
a  small  part  of  a  constitutional  condition  which  requires 


IV  PREFACE. 

treatment,  leaving  the  uterine  or  other  ailment  to  disap- 
pear of  itself  when  the  general  health  becomes  restored. 
The  diagnosis  of  functional  disease  should  be  carefully 
made,  for  even  in  chronic  organic  cases  many  important 
organic  changes  take  place  without  the  accompanying 
physical  signs,  and  to  determine  the  question  whether  an 
ailment  is  functional  or  organic  will  at  times  completely 
mystify  the  most  competent  and  astute  phj'sician.  It  is 
hoped  that  this  contribution  will  be  of  interest  and  some 
practical  advantage  to  the  general  practitioner,  from 
whose  standpoint  it  is  written,  and  of  value  to  future  ex- 
plorers in  this  interesting  department  of  medical  work. 

776  Madison  Avenue,   New  York. 


CONTENTS. 


CHAPTER  I. 

PAGE 

The  Reflex  Neueoses, 1 

CHAPTER  II. 
The  Cerebral  Neuroses,  or  Psychoses, 27 

CHAPTER  III. 
Spinal  Reflex  Neuroses, 34 

CHAPTER  IV. 
Cardiac  Reflex  Neuroses, 43 

CHAPTER  V. 

Vascular  Neuroses, .47 

CHAPTER  VI. 
Pharyngeal  and  Laryngeal  Reflex  Neuroses,     .        .        .81 

CHAPTER  VII. 
Bronchial  Reflex  Neuroses, 85 

CHAPTER  VIII. 

Gastric  Reflex  Neuroses, 89 

^*CHAPTER   IX. 
Intestinal  Reflex  Neuroses,     .        .        .        .        .       .        .98 

CHAPTER   X. 
The  Renal  Reflex  Neuroses, 106 

CHAPTER    XL 
The  Vesical  Reflex  Neuroses,         .        .        .        .        .        .108 


VI  CONTENTS. 

CHAPTER  XII. 

PAGE 

The  Reflex  Genital,  or  Hystero- Neuroses,  .        .        .  113 

CHAPTER  XIII. 
The  Glandular  Reflex  Neuroses 118 

CHAPTER  Xr\^. 
Ophthalmic  Reflex  Neuroses, 128 

CHAPTER    XV. 
The  Aural  Reflex  Neuroses, 137 

CHAPTER  XVI. 
Limgual  Reflex  Neuroses, 140 

CHAPTER  XVII. 
The  Articular  Reflex  Neuroses, 144 

CHAPTER  XVIII. 
The  Dermal  Reflex  Neuroses  or  Dermatoses,     .        .        .  149 

CHAPTER  XIX. 
Hysteria, 157 

CHAPTER   XX. 
Hystero -Epilepsy 183 

CHAPTER   XXI. 
Hemicrania— Migraine,        .        .        .  .        .        .        .  243 

CHAPTER  XXII. 
Therapeutics, 251 


FUI^CTIONAL  DISORDERS 


OF  THE 


NERVOUS    SYSTEM   IN   WOMEN. 


CHAPTER  I. 
THE  REFLEX  NEUROSES. 

Every  woman  suffers  more  or  less,  and  many  almost 
constantly,  from  functional  derangements  of  some  of  the 
organic  structures  of  the  body.  We  are  frequently  con- 
sulted by  those  who,  although  suffering  from  no  gross 
pathological  condition,  nevertheless  require  our  aid  for 
the  great  discomforts,  both  physical  and  mental,  which 
these  various  functional  disturbances  entail,  and  we  should 
make  every  effort  to  afford  them  consolation  and  relief. 

Many  of  these  simple  deviations  from  the  normal  are 
really  precursors  of  conditions  of  a  most  serious  nature. 
There  is  every  reason  to  investigate  carefully  these  minor 
ailments,  because  of  their  great  frequency  and  the  impor- 
tant bearing  they  have  upon  our  success  as  practitioners. 

It  is  often  claimed  that  many  physicians  are  too  scienti- 
fic and  not  sufficiently  practical  in  their  treatment  of  jja- 
tients.  This  is  a  matter  we  should  guard  against,  because 
the  physician's  duty  is  first  and  foremost  that  of  healing 
and  not  altogether  that  of  solving  scientific  problems.  No 
scientific  physician  is  pleased  when  he  finds  he  has  lost 


2  FUNCTIONAL   NERVOUS    DISORDERS. 

some  of  his  patients  because  they  have  been  discontented 
and  annoj^ed  at  his  lack  of  interest  and  sympathy  for 
their  minor  functional  disturbances,  and  that  an  arrant 
impostor  has  them  in  charge,  because,  by  his  tact  and 
knowledge  of  human  nature,  he  has  readily  relieved  their 
imaginary  or  trifling  ailments.  Old  ladies  and  lay 
persons  generally  are  often  loud  in  their  praises  of  these 
irregular  practitioners  simply  because  they  have  given  at- 
tention to  these  minor  difficulties. 

Among  the  more  important  of  these  lesser  derange- 
ments are  the  reflex  neuroses,  which  will  be  considered 
from  the  standpoint  of  the  general  practitioner  or  gynae- 
cologist. There  are  many  who  seem  to  consider  them 
insignificant,  and  some  even  appear  to  doubt  their  actual 
existence. 

The  reflex  neuroses  are,  of  course,  symptoms,  but  yet  are 
more  than  simple  symptoms  as  they  are  frequently  pro- 
ductive of  more  distress  than  the  organic  disease  from 
which  they  take  their  origin. 

Neurosis  is  a  generic  term  for  conditions  of  hyperaes- 
thesia  or  disturbance  of  the  nervous  system  which  simu- 
late disease  in  an  organ  that  is  healthy,  or  without  evident 
lesion  of  any  of  its  parts.  They  may  be  general  or  local. 
Every  general  practitioner  should  be  well  acquainted  with 
them,  and  every  specialist  also.  The  latter  must  first  have 
the  knowledge  of  the  general  practitioner,  otherwise  many 
mistakes  will  certainly  be  made  in  the  diagnosis  and  treat- 
ment of  chronic  ailments.  For  example,  if  the  confiding 
and  unsuspecting  patient  with  a  run-down  constitution — 
the  result  of  anxiety,  bad  air,  and  a  worse  diet — with  a 
headache  and  some  abdominal  or  uterine  symptoms,  strays 
into  the  office  of  an  enthusiast  in  ocular  tenotomy,  he  will 
probably  want  to  relieve  her  distress  by  dividing  the  rec- 


THE    KEFLEX    NEUROSES.  3 

tus  muscle  for  eye-strain.  If,  however,  as  is  more  likely, 
she  applies  to  a  surgical  gynaecologist  of  a  certain  class,  a 
symptomatic  uterine  catarrh,  an  inoff ending  laceration,  or 
a  harmless,  retiring  cystic  ovary  will  he  pounced  upon  by 
this  enlightened  specialist,  and  receive  most  vigorous  treat- 
ment; and  if  he  does  not  alwaj's  sterilize  carefully  his  "in- 
struments he  usually  succeeds  in  sterilizing  the  patient. 
Or  perhaps  her  destiny  may  lead  her  into  the  office  of  a 
digestive  specialist,  who,  of  course,  diagnoses  stomach  trou- 
ble as  the  cause  of  all  her  ills,  and  proceeds  to  lower  sev- 
eral feet  of  rubber  hose  into  her  surprised  stomach,  and 
treat  that  organ  to  a  wholesome  bath.  If  our  specialism 
be  allowed  to  run  into  exclusivism,  very  shortly  the  only 
safe  man  for  a  patient  to  consult  will  be  the  old-fashioned 
general  practitioner  with  all  his  faults  and  deficiencies. 
The  benefits  of  specialism  are  many  and  most  important, 
but  there  are  also  some  dangers  to  be  avoided. 

The  neuroses  of  women  should  be  studied  carefully  from 
both  an  anatomical  and  physiological  standpoint.  There 
is  indeed  much  yet  to  be  learned  and  plainly  stated.  The 
nervous  system  must  be  studied  by  the  general  practi- 
tioner as  well  as  by  the  specialist,  otherwise  he  is  shut  out 
from  a  true  knowledge  of  disease.  The  important  bear- 
ing of  nutrition  upon  all  ailments  must  be  carefully  con- 
sidered before  a  practical  common-sense  solution  of  the 
many  difficult  problems  which  present  themselves  can  be 
reached. 

That  many  nervous  disorders  are  caused  reflexly,  there 
can  be  no  doubt.  There  is  much  difference  of  opinion  in 
regard  to  the  causation  of  the  various  neuroses,  but  many 
cases  are  recorded  illustrating  the  fact  that  peripheral 
irritation  is  a  very  decided  factor  in  their  production. 
Irritation  may  be  set  up  in  any  part  of  the  body,  and  may 


4  FUXCTIONAL   NERVOUS    DISORDERS. 

result  in  a  reflex  disorder  in  a  distant  organ.     Some  of 
the  sources  of  irritation  which  may  be  noted  are: 

In  the  Digestive  Organs — Indigestion. 
a.  Stomach — Gastric  catarrh,  ulcer. 
h.  Intestines — Parasites, ulcers, intestinal  catarrh. 
f  Haemorrhoids. 
Ulcers. 


c.   Rectum-,  ^^^^^^^  ^^^^^ 
1^  Pruritus  ani. 

In  the  Genito-Urinary  Organs — Inflammations. 

Internal — 

a.  Kidneys — Calculus. 

7,    -rn   jj  'i  Calculus. 

h.   Bladder-  \  Catarrhal  states. 

^       .  j  Inflammations. 

c.  uvaries—  ^  ^^^^iid^  growths. 

7    TT  )  Inflammations. 

d.  Uterus-  -j  Morbid  growths. 
External — 

a.  Vulva — Pruritus,  herpes. 
h.   Clitoris — Adhesions. 

(  Inflammation. 
In  the  Respiratory  Organs —  ■<  Irritation  (catarrhal) . 

(  New  growths. 

T  T7.  i  Eye  strain. 

/  Errors  of  refraction  and  accommodation. 

J  -pj  Abscess. 

IN  the  JiARS       ^  iinpacted  cerumen. 

The  foregoing  is  by  no  means  a  complete  summary  of 
the  causative  factors  which  operate  in  the  production  of 
reflex  disturbances,  yet  they  are  fair  examples  of  what  we 
should  look  for  when  searching  for  some  peripheral  irrita- 
tion to  assist  us  in  the  diagnosis  and  treatment  of  disease. 

Although  severe  local  disease  may  exist  in  an  organ 
with  but  little  reflex  disturbance,  still,  usually  many  re- 
flex nervous  disorders  depend  on  slight  peripheral  irrita- 


THE    KEFLEX    LEUKOSES.  O 

tions;  and  these  reflex  irritations,  if  they  are  not  the  abso- 
lute and  complete  causes  of  the  nervous  phenomena,  are 
certainly  exciting  causes  in  those  individuals  who  have 
a  predisposing  temperament. 

No  one  has  more  thoroughly  investigated  the  reflex 
hystero-neuroses  than  Dr.  George  J.  Engelmann,  of  St. 
Louis,  whose  contributions  on  this  subject  are  extremely 
valuable.  Both  the  sympathetic  and  the  spinal  systems 
are  involved,  and  a  condition  of  ansemia  or  lowered  vital- 
ity is  the  most  important  causative  agent  in  producing  the 
hypersensitiveness  of  the  nervous  system.  This  weak- 
ness is  the  most  prominent  factor  in  the  disorder.  The 
study  of  the  subject  is  of  the  greatest  importance  in  the 
diagnosis  of  disease — for  instance,  asthma,  which  one  may 
be  led  to  consider  a  local  pulmonary  or  cardiac  disease,  is 
often  of  reflex  origin,  either  from  the  uterus,  gastro-intes- 
tinal  tract,  or  from  localized  growths  in  the  posterior 
nares.  The  spasmodic  croup  and  convulsions  in  children 
are  good  examples  of  reflex  nervous  action. 

Reflex  or  nervous  diarrhoea  is  often  seen  in  horses  and 
other  animals.  It  is  also  very  common  as  an  intestinal 
neurosis  in  the  human  subject,  and  is  a  result  of  distur- 
bances of  the  sympathetic  system  through  mental  influ- 
ences. The  condition  is  analogous  to  that  where  the 
sound  of  running  water  causes  a  reflex  stimulation  of  the 
renal  glands,  thus  assisting  urination. 

Strong  mental  impressions  stimulate  both  the  vesical 
and  rectal  nerves  of  the  young  soldier  when  going  into 
battle  for  the  first  time,  while  the  uterine  nerves  in  the 
young  female  emigrant  produce  amenorrhoea  from  the  ex- 
citement incident  to  leaving  home  and  coming  to  a  for- 
eign country.  The  diarrhoea  of  scared  soldiers  and  of 
nervous  horses  is  of  similar  origin,  and   the  emission  of 


6  FUNCTIONAL   NEEVOUS    DISORDERS. 

the  malodorous  fluid  of  the  Mephiticus  americanus  when 
pursued  or  frightened  may  be  explained  in  the  same  way. 

The  differential  diagnosis  between  a  severe  reflex  head- 
ache depending  upon  uterine  or  digestive  disease,  such  as 
pelvic  cellulitis  or  indigestion  with  constipation,  and  be- 
ginning exophthalmic  goitre,  where  a  rapid  pulse  and 
swollen  thyroid  are  among  the  earliest  manifestations,  is 
often  exceedingly  difficult,  as  the  mere  fact  of  entering 
a  physician's  office  for  examination  will  often  produce  in 
nervous  young  women  a  great  amount  of  excitability. 
This  may  give  rise  not  only  to  a  rapid  pulse,  but  also 
produce  a  globus  hystericus — itself  possibly  a  temporary 
congestion  of  the  thyroid.  Many  of  these  reflex  condi- 
tions are  certainly  common  and  are  yet  not  always  appre- 
ciated at  their  true  value.  They  should  be  carefully  stud- 
ied in  order  that  the  differentiation  between  functional  and 
organic  or  structural  disease  in  an  organ  may  be  readily 
determined.  They  are  of  interest  not  only  to  the  gynae- 
cologist, on  account  of  their  frequency  in  women,  but  to  the 
aurist,  the  oculist,  the  dermatologist,  the  neurologist,  and 
the  surgeon.  In  this  class  of  cases,  although  the  uterus  is 
a  great  factor  in  their  production,  the  stomach  and  intes- 
tines play  fully  as  important,  if  not  a  greater  part.  They 
may  be  divided  according  to  the  following  classification. 

The  neuroses  of  the  nervous  system. 

The  neuroses  of  the  circulatory  system. 

The  neuroses  of  the  digestive  system. 

The  neuroses  of  the  respiratory  system. 

The  neuroses  of  the  genito-urinary  system. 

The  neuroses  of  the  glandular  system. 

The  neuroses  of  the  cutaneous  system. 

The  spinal  and  cerebral  centres  are  not  only  implicated 
in    these  disorders,    but  the    ganglionic   and  vasomotor 


THE    KEFLEX    XEUROSES.  7 

nerves  probably  even  more  so.  Tbis  is  readily  seen  in  tbe 
flushes,  perspirations,  or  blanching  of  tbe  surface  of  tbe 
body.  Tbe  cardiac  and  solar  plexuses  are  "without  doubt 
of  great  importance  in  these  ganglionic  disturbances. 
The  reflex  neuroses  are  not  to  be  confounded  with  symp- 
toms from  local  mechanical  pressure — mere  local  inflam- 
matory neuralgia.  They  may,  however,  cause  severe 
pain.  Ever}''  one  is  familiar  with  the  common  reflex  neu- 
roses— e.g.,  those  of  pregnancy — but  it  is  with  the  less 
common,  but  no  less  interesting  varieties  that  we  are 
concerned  at  present.  They  are  important  on  account  of 
their  misleading  qualities,  and  are  of  great  practical  im- 
port in  the  daily  routine  of  medical  practice. 

These  are  the  symptoms  which  connect  general  with 
special  medicine,  and  without  a  knowledge  of  them  the 
practitioner  no  longer  remains  a  scientific  physician, 
but  gradually  drifting  into  exclusivism,  becomes  little 
more  than  a  skilled  mechanic,  and  under  his  care  the 
wrong  organ  will  often  receive  the  benefit  of  the  medica- 
tion. 

Comparatively  little  has  been  written  upon  this  subject. 
Fordyce  Barker  was  well  aware  of  its  importance,  and 
wrote  a  work  dealing  with  some  of  the  bystero-psj^choses, 
entitled  "  Uterine  Disease,  an  Exciting  Cause  of  Insan- 
ity." Hodge  and  Tilt  have  recorded  many  cases.  Hegar 
has  studied  them,  and  has  shown  also  their  importance  in 
gynsecology.  The  alienist  Esquirol  has  pointed  out  their 
connection  with  insanity.  Dr.  Engelmann  has  given  them 
special  study  in  an  elaborate  article  in  the  Gj^nsecological 
Transactions  for  1887,  and  Dr.  H.  J.  Boldt  has  described 
the  "Cardiac  Neuroses  in  Connection  with  Ovarian  and 
Uterine  Disease"  in  an  interesting  article  in  the  American 
Journal  of  Obstetrics  for  August,  1886.     A  number  of 


8  PUNCTION^AL    NERVOUS    DISORDERS, 

other  writers  have  also  enlarged  upon  this  interesting 
subject. 

The  frequency  of  hystero-neuroses  may  be  judged  when 
Dr.  Engelmann  states  that  he  has  observed  in  private 
practice,  in  the  ten  years  since  writing  his  first  paper  in 
1877,  over  a  thousand  cases  of  menstrual  hystero  neuroses 
of  the  stomach  alone. 

The  intimate  connection,  reflexly,  between  the  uterine 
and  digestive  organs  is  often  manifested  by  gastralgia  in 
cases  of  retroversion,  the  cure  of  the  retroversion  causing 
the  immediate  and  permanent  disappearance  of  the  pain 
in  most  cases.  Cases  of  violent  vomiting  occurring  during 
the  act  of  coition  have  been  noted.  Here,  in  this  true  re- 
flex neurosis  there  is  generally  an  excessive  secretion  of 
hydrochloric  acid.  A  case  of  this  kind  has  been  recently 
reported  in  the  Medical  Record  by  Dr.  M.  Gross.  The 
digestive  disorders  are  frequent  causes  reflexly  of  genital 
weakness,  although  anaemia  may  also  be  present. 

No  part  of  the  body  should  be  regarded  as  an  indepen- 
dent tissue,  as  each  one  holds  the  closest  relations  with  the 
rest  of  the  system  and  is  always  influenced  by  morbid 
conditions  in  the  other  parts. 

Digestive  and  uterine  disorders  at  the  menopause  fre- 
quently manifest  themselves  by  reflex  disturbances  of 
sensation  in  the  lower  extremities.  One  of  the  curious 
symptoms  of  such  disturbance  is  diminished  sensibility 
and  a  feehng  as  if  the  patient  were  walking  over  feather 
beds,  or  large  puff  balls,  and  sinking  at  every  step.  Cramps 
of  the  muscles  of  the  calf  of  the  leg  are  also  of  common 
occurrence  in  these  disorders.  These  cramps  are,  in  my 
opinion,  of  vasomotor  origin,  and  when  attacking  the  toes 
or  calves,  are  similar  in  many  respects  to  migraine.  It  is 
not  alone  a  muscular  cramp,  the  circulation  being  prin- 


THE    REFLEX    NEUEOSIS,  9 

cipally  disturbed.  There  is  much  between  the  two  that 
is  analogous. 

Almost  every  gynaecological  surgeon,  who  has  given  the 
matter  any  attention,  has  seen  reflex  neuroses  dependent 
upon  lacerated  cervix.  The  scar  tissue  probably  inclurles 
nerve  filaments,  and  so  keeps  up  a  persistent  irritation.  It 
is  not  the  specialist  but  the  general  practitioner  who  is 
most  liable  to  discover  the  various  reflex  neuroses  and 
give  them  their  proper  weight  and  treatment. 

No  attempt  whatever  has  been  made  to  go  into  the  sub- 
ject exhaustively.  It  is  simply  desired  to  speak  of  symp- 
toms and  conditions  which  are  commonly  met  with,  espe- 
cially in  women  patients,  and  to  consider  some  of  the 
disorders  which  lie  in  that  comparatively  unknown  region 
between  gynaecological  surgery  and  general  medicine. 

It  is  to  be  regretted  that  many  gynaecologists,  in  the  treat- 
ment of  diseases  of  women,  never  permit  their  range  of  vis- 
ion to  extend  beyond  the  pelvis.  This  is  more  particularly 
so  in  the  case  of  the  younger  physicians  who  become  spe- 
cialists immediately  upon  graduating,  and  who  have  never 
had  the  advantages  to  be  derived  from  a  general  practice. 

Neuroses  of  ophthalmic  nature  require  careful  investi- 
gation of  the  digestive  function,  the  kidneys,  and  the 
uterus.  A  regulation  of  the  diet,  or  some  gynaecological 
treatment,  is  often  all  that  is  required.  Many  cases  of 
apparent  gastric  disease  have  been  treated  for  years  by 
medication  directed  to  the  stomach,  when  an  endometritis 
was  the  principal  causative  factor  in  the  production  of  the 
symptoms.  And  vice  versa  many  a  leucorrhoea  has  been 
treated  locally  by  douches  and  astringents  when  chronic 
dyspepsia  and  hepatic  congestion  were  responsible  for  its 
continuance.  Through  the  ramifications  of  the  spinal 
and  ganglionic  nerves  irritation  in  one  part  of  the  body 


10  FUNCTIONAL   NERVOUS    DISORDEES. 

shows  itself  in  distant  organs.  Thus,  cerebral  irritations 
may  expend  their  force  in  gastric  distress,  and  again, 
most  of  the  headaches  from  which  patients  suffer  are  the 
result  of  disturbances  within  the  abdominal  and  pelvic  cav- 
ities. By  a  series  of  plates  illustrating  this  subject  it  is 
hoped  to  exhibit  in  a  graphic  manner  certain  pathological 
facts,  and  still  further  to  establish  certain  connections  and 
functions  of  the  ganglionic  system  in  order  that  some  ob- 
scurities in  the  physiology  of  the  nervous  system  may  pos- 
sibly be  removed. 

A  thorough  knowledge  of  these  reflex  symptoms  is  ex- 
tremely important,  as  it  helps  to  broaden  the  domain  of 
medical  treatment,  and  careful  study  of  the  subject  will 
increase  the  usefulness  of  both  specialist  and  general  prac- 
titioner, and  tend  to  promote  more  harmonious  relations 
between  the  different  branches  of  medical  science.  The 
methods  of  treatment  of  the  old-fashioned  general  practi- 
tioner are  much  more  to  be  commended  in  the  treatment 
of  uterine  disease  than  are  those  of  some  of  the  up-to-date 
gynaecologists,  who  think  it  their  bounden  duty  to  make  a 
digital  and  visual  examination  of  every  patient,  married 
or  single,  who  enters  their  offices,  regardless  of  the  fact 
that  the  uterine  symptoms  are  simply  the  results  of  over- 
work, bad  hygiene,  and  poor  diet,  the  rectification  of  which 
would  cause  them  speedily  to  disappear,  or  of  local  con- 
ditions alone.  It  is  really  criminal  to  make  a  physical 
uterine  examination  of  a  young  unmarried  woman  unless 
such  a  course  is  unmistakably  indicated.  The  great  ma- 
jority of  these  cases  do  not  call  for  any  such  procedure. 
In  the  married  it  is  entirely  different,  and  examinations 
may  be  made  much  more  freely. 

I  have  seen  violent  attacks  of  apnoea  produced  by  uter- 
ine disease,  and  many  of  the  cerebral  neuroses  are  the  re- 


THE    KEFLEX    LEUKOSES.  11 

suits  of  irritations  springing  up  in  the  gastro-intestinal 
tract.  Much  of  the  irritability,  bad  temper,  and  moral 
perversion  takes  its  origin  in  the  abdominal  cavity.  The 
differential  diagnosis  between  a  reflex  neurosis  and  a  local 
inflammatory  condition  is  often  difiicult,  and  many  times 
the  two  are  combined.  When  the  neurosis  is  present  the 
symptoms  are  out  of  proportion  to  the  local  pathological 
changes.  We  find  lesions  and  pathological  conditions 
existing  in  various  parts  of  the  body  which,  increasing  in 
severity,  increase  correspondingly  the  severity  of  the  neu- 
rosis, and  treatment  directed  to  these  pathological  states 
decreases  the  neurosis  or  causes  its  disappearance,  while 
local  remedies  applied  directly  to  the  seat  of  the  neurosis 
are  productive  of  no  benefit. 

Some  of  the  neuroses  are  very  persistent.  Cases  of 
hemianaesthesia,  hemiplegia,  and  paraplegia  lasting  for 
years  have  frequently  been  seen. 

I  am  led  to  believe  that  in  the  reflex  neuroses  there  is 
undoubtedly  local  congestion  dependent  on  the  irritation. 
In  the  globus  hystericus  in  many  instances  this  con- 
gestion can  be  determined  by  placing  the  finger,  during 
its  existence,  on  the  front  of  the  throat  just  below  the  lar- 
ynx, where  it  will  be  found  very  tender  to  the  slightest 
pressure. 

The  digestive  and  genital  organs  of  women  are  so  inti- 
mately connected  by  their  nervous  and  vascular  relations 
that  to  treat  them  separately,  and  yet  successfully,  is  im- 
possible, therefore  it  is  readily  seen  how  important  it  is 
for  every  gynsecologist  to  be  thoroughly  familiar  with  the 
digestive  disorders.  As  I  have  already  said  in  an  article, 
the  uterus,  tubes,  and  ovaries  are  often  treated  as  if  they 
were  in  no  way  connected  with  each  other ;  so  it  is  with 
the   digestive   tract.      Its    connection   with    the    genital 


12  FUN"CTIOXAL    XEKVOUS    DISOEDERS. 

organs  is  so  extremely  intimate  that  neither  of  them 
should  be  treated  without  a  careful  investigation  of  the 
other,  lying  as  they  do  in  the  same  cavity,  with  the  same 
vascular  and  nerve  supply. 

The  skin,  digestive  and  nervous  systems  are  very  inti- 
mately connected.  Dermatoses,  where  the  eruption  covers 
the  nose  and  upper  part  of  the  cheeks  in  butterfly  form,  are 
very  common  in  the  country  districts  where  large  quanti- 
ties of  indigestible  fried  foods  are  eaten.  The  dermatoses 
of  reflex  origin  are  very  numerous.  The  laryngologist 
and  rhinologist  also  should  give  special  attention  to  these 
disorders. 

Dr.  S.  C,  a  personal  friend,  tells  me  that  every  month 
or  two,  when  suffering  from  an  attack  of  aggravated  indi- 
gestion, he  also  has  regularly  a  severe  pharyngeal  and  ton- 
sillar inflammation  accompanying  it.  This,  however, 
might  be  due  to  an  extension  of  the  disease  by  continuity 
along  the  oesophagus.  Yet  it  is  probably  of  reflex  origin. 
Dr.  L.,  after  a  continued  indulgence  in  strong  coffee,  is 
always  attacked  with  severe  congestion  of  the  nasal 
mucous  membrane,  and  cor3'za,  which  in  this  case  is 
nothing  more  than  a  reflex  neurosis.  These  reflex  symp- 
toms have  been  to  a  great  extent  ignored  b}'  the  profession 
as  a  whole.  The  ancient  Romans  recognized  the  conges- 
tion and  enlargement  of  the  thyroid  as  a  result  of  uterine 
irritation. 

Probably  the  most  common  of  all  the  neuroses  is  the 
well-known  morning  sickness  of  pregnancy;  migraine, 
and  other  types  of  headache  dependent  on  gastric  and 
liver  disturbances  are  also  good  examples  of  the  reflex 
neuroses. 

It  is  not  supposed  that  grave  diseases,  such  as  epilepsy, 
chronic  mania,  and  other  organic  diseases  of  the  nervous 


THE    REFLEX    XEUROSES.  13 

system,  are  dependent  upon  slight  peripheral  irritations, 
but  it  is  certain  that  many  important  and  decided  func- 
tional disorders  are.  On  the  other  hand,  it  may  be  said 
that  there  is  not  the  slightest  doubt  that  there  have  been 
many  errors  in  ascribing  conditions  depending  upon  a 
general  blood  state,  the  result  of  mal-assimilation  or  auto- 
infection,  to  some  slight  peripheral  disturbance.  Some 
physicians  are  inclined  to  repudiate  entirely  the  reflex 
theory  of  functional  disorders,  and  this  seems  to  have  been 
quite  fashionable  of  late.  The  study  of  the  reflex  neu- 
roses is  nothing  more  than  a  study  of  the  symptoms  of 
disease  which  manifest  themselves  in  distant  portions  of 
the  body. 

A  perfect  classification  of  the  reflex  neuroses  of  individ- 
ual organs  is  at  present  impossible,  but  for  clinical  pur- 
poses we  may  include  the  following  among  the  more  com- 
mon forms : 

1.  Cerebral.  10.  Renal. 

3.  Spinal.  11.  Vesical. 

3.  Cardiac.  12.  Genital. 

4.  Vascular.  13.  Glandular. 

5.  Pharyngeal.  14.  Ophthalmic. 

6.  Laryngeal.  15.  Aural. 

7.  Bronchial.  16.  Lingual. 

8.  Gastric.  17.  Articular. 

9.  Intestinal.  18.  Dermal. 

Many  of  these  are  combined,  as  in  the  cerebro-spinal  and 
gastro-intestinal.  And  two  or  more  may  exist  at  the 
same  time,  as  gastric  and  dermal,  cardiac  and  respiratory, 
vascular  and  glandular. 

In  his  article  "A  Clinical  Study  of  ISTeuralgias,"  in  the 
]S!eiv  Yor^k  Medical  Journal,  July  30th,  1887,  Dr.  Dana 


14  FUISrCTIONAL   NERVOUS    DISORDERS. 

says  in  speaking  of  The  Origin  of  "  Reflex"  or  Transferred 
Neuralgias  and  Pain: 

"  No  point  connected  with  the  clinical  history  of  neural- 
gias is  of  more  interest  than  that  of  their  so-called  'reflex' 
origin.  The  production  of  migraine  has  been  attributed, 
as  we  have  seen,  to  the  stomach  and  liver,  to  the  eye,  the 
tonsils,  and  the  nose.  Digital,  plantar,  cardiac,  intercos- 
tal, and,  in  fact,  all  the  neuralgias  have  been  attributed  to 
extrinsic  causes.  So  much  has  appeared  in  literature  re- 
garding the  effects  of  such  remote  irritation  that  the  im- 
portance of  this  influence  has  perhaps  become  exaggerated. 
At  the  same  time  the  subject  is  one  deserving  of  further 
and  persistent  study  until  its  present  many  obscurities  are 
removed. 

"  In  this  study  it  is  to  be  remembered  that  the  term  re- 
flex used  here  is  not  technically  a  correct  one.  An  irrita- 
tion in  the  stomach  may  cause  a  pain  which  is  felt  in  the 
forehead.  The  impulse,  starting  in  the  stomach  nerves, 
is  conveyed  to  the  co-rtex  of  the  brain,  and  this  is  felt  as  a 
sensation  excited  by  the  trigeminal  nerve.  It  is  a  trans- 
ferred sensation,  not  a  reflex  one,  since  the  impulse  is 
afferent  only,  and  the  outward  reference  of  the  pain  is 
purely  psychical. 

"Reflex  pains  are,  therefore,  really  'transferred  pains,' 
as  a  rule.  In  some  cases  it  may  be,  however,  that  irrita- 
tions provoke  reflex  vasomotor  changes  in  remote  parts, 
and  the  anaemia  or  congestion  thus  produced  causes  pain. 
There  may  be,  therefore,  'indirectly  produced  reflex 
pains.'  The  term  reflex  pain  is  so  widely  used  that  I  can- 
not attempt  to  discard  it.  I  use  it,  however,  with  the  ex- 
planation here  given.   .  .  . 

"Irritations  from  the  stomach  cause  reflexly  a  larger 
variety  of  pains.     It  is  not  possible  to  decide  always 


THE    EEFLEX    LEUKOSES.  15 

whether  these  pains  are  reflex,  or  are  due  to  vaso-motor 
disturbances  or  the  circulation  of  morbid  products  in  the 
blood  as  in  cases  of  fermentative  dyspepsia,  and  of  consti- 
pation associated  with  dyspepsia. 

"  We  all  know  that  the  simple  ingestion  of  a  glass  of  ice- 
water  will  cause  a  sharp  frontal  or  temporal  pain.  Lau- 
der Brunton  finds  that  constipation  and  presumable  intes- 
tinal irritation  cause  a  diffuse  frontal  headache  over  the 
whole  brow.  When  there  is  no  constipation  and  the  con- 
dition is  one  of  gastric  irritation  the  pain  is  either  just 
above  the  eyes,  or  more  rarely  in  the  occiput  (when  it  will 
be  relieved  by  acids) ,  or  just  at  the  roots  of  the  hair  (when 
it  will  be  relieved  by  alkalies).   .  .  . 

"  The  scapular  or  shoulder  pains  in  dyspepsia,  and  the 
pains  felt  between  the  scapulae,  due  to  the  involvement  of 
the  posterior  branches  of  the  second  to  the  sixth  intercos- 
tal nerves,  are  common  phenomena  familiar  to  all. 

"  Gastric  irritations  must  have  a  certain  severity  to  be 
felt  as  pain  in  the  stomach  or  epigastrium,  and  in  these 
cases  there  is  doubtless,  as  a  rule,  some  muscular  spasm 
of  the  stomach  walls. 

"The  milder  irritations  produced  by  gas,  undigested 
food,  excess  of  acid,  etc.,  seem  to  be  reflected  most  often 
upon  the  upper  intercostal  nerves  or  the  cardiac  nerves, 
vagal  or  sympathetic.  The  headaches  in  gastric  irrita- 
tion so  often  involve  some  toxic  element  that  we  cannot 
speak  of  their  origin  with  much  positiveness. 

"  The  stomach  and  intestines  are  probably  the  most  fre- 
quent cause  of  transferred  pains;  after  this  I  would  place 
the  uterus  and  its  appendages,  and  next  the  eye  or  heart. 
Lange  considers  that  the  heart  ranks  second. 

"  In  kidney  disease  neuralgic  pains  may  be  felt  in  the 
lumbar  region,  radiating  forward  to  the  lower  abdomen 


16  FUNCTIOXAL   NERVOUS    DISORDERS. 

and  genitals — in  other  words,  a  lumbo-abdominal  neural- 
gia is  produced.  In  a  case  of  renal  colic  I  have  observed 
the  pain  to  be  I'epeatedly  centred  about  the  anterior  supe- 
rior crest  of  the  ilium. 

"Pains  started  up  by  the  gall-bladder  are  felt  in  the 
right  side  of  the  thorax  and  right  arm,  while  it  is  one  of 
the  aphorisms  of  medicine  that  disorders  of  the  liver  may 
cause  pain  in  the  right  shoulder.  Bilious  headaches 
cured  by  a  dose  of  calomel  I  have  observed  to  be  located 
sometimes  in  the  vertex  and  occiput. 

"  In  abscess  of  the  spleen  there  is  a  pain  felt  in  the  left 
shoulder  (Grotonelli,  Wardell). 

"Langesays  {loc.  cit.)  that  in  uterine  troubles  the  re- 
flex pains  occur  oftenest  in  the  form  of  arthralgias.  I 
have  had  a  patient  suffering  with  painful  spasms  of  the 
bladder  who  had  intense  pain  in  the  palms  of  the  hands 
every  time  she  had  a.  bladder  spasm  {Medical  Recoixl, 
July  25th,  1885) ;  another  patient,  while  pregnant,  suf- 
fered from  digital  neuralgia,  and  in  a  third  case  reported 
by  myself,  a  patient  of  Dr.  Nilsen's,  suffering  from  ova- 
rian prolapse,  had  severe  and  continuous  neuralgic  pains 
in  the  wrist.  Studies  of  the  cause  of  reflex  pains  in  the 
feet  show  that  they  may  be  referred  in  almost  all  cases  to 
irritation  of  the  genito-urinary  tract,  and  occur  more  often 
in  the  male  {Medical  Record,  July  25th,  1885).  The 
pains  of  uterine  disorder,  when  reflected  down,  appear 
rarely  to  go  below  the  knee;  in  other  words,  they  affect 
the  lower  branches  of  the  lumbar  plexus,  and  not  the 
sacral  nerves. 

"  It  has  been  stated  that  pain  in  the  heels  may  be  caused 
by  ovarian  abscess.  In  my  experience,  such  pains  are 
due  to  lithsemic  and  neurasthenic  conditions,  and  will  be 
relieved  by  remedies  addressed  to  such  states.     It  may  be 


THE    REFLEX    XEUE0SE3.  17 

said  in  general,  then,  that  pelvic  irritations  are  felt  most 
frequently  in  the  upper  and  short  branches  of  the  lumbar 
plexus,  next  perhaps  in  the  intercostal  nerves  and  upper 
cervical  nerves,  then  in  the  trigeminus,  and  last  in  the 
hands  and  feet. 

"  Lesions  in  the  lung  itself  cause  reflex  pains  in  the 
form  of  intercostal  neuralgia.  Slight  pulmonary  conges- 
tions, such  as  occur  at  the  very  onset  of  phthisis,  may 
cause  intercostal  neuralgia,  and  Anstie  speaks  of  the  value 
of  these  pains  as  warnings  of  the  approach  of  phthisical 
disease.  Apart  from  these  neuralgias,  the  lung  is  very 
rarely  an  excitant  of  reflex  pains,  perhaps  because  its 
nerve  supply  is  small,  aside  from  the  sensory  fibres  of  the 
vagus.  Further  studj",  however,  may  show  that  lung 
irritation  may  cause  some  of  the  painful  affections  of  the 
larynx,  tongue,  or  throat. 

"  The  question  now  arises  whether,  with  these  various 
facts  before  us,  any  general  statements  can  be  made  with 
regard  to  the  production  of  transferred  pains.  If  we 
study  them  in  connection  with  the  anatomical  arrange- 
ments of  the  cerebro-spinal  and  so-called  sympathetic  sys- 
tem, it  is  possible  that  the  diffusion  and  transference  of 
pain,  though  in  'a  mighty  maze,'  will  not  appear  entirely 
without  a  plan, 

"  The  cerebro-spinal  nerves  are  sent  out  from  their  cen- 
tres in  divisions  or  companies  of  seven,  and  each  company 
acts  together  and  serves  a  common  definite  physiological 
purpose.     These  divisions  are : 

"1.  The  oculo-motor  nerves,  the  trifacial,  and  the  sev- 
enth— which  supply  motion  and  feeling  to  the  face  and 
anterior  scalp.  The  remaining  cranial  nerves  supply  in- 
ternal parts. 

"  2.  The  four  upper  cervical  nerves  forming  the  cervical 

2 


18  FUIS'CTIONAL   NERVOUS    DISORDERS. 

plexus.  This  leash  of  nerves  supplies  motion  and  sensa- 
tion to  the  neck  and  occiput,  and  controls  the  movements 
of  the  cephalic  extremity.  It  is  in  close  connection  with 
the  trifacial,  both  at  its  origin  and  periphery,  both  di- 
rectly and  via  the  sympathetic.  It  is  subjected  to  much 
the  same  disturbances,  and  may  be  looked  upon  as  physio- 
logically almost  a  part  of  the  first  set — i.e.,  of  the  com- 
mon sensor i -motor  cranial  nerves. 

"  3.  The  third  leash  of  nerves  is  composed  of  the  last 
four  cervical  and  first  dorsal.  They  form  the  brachial 
plexus,  and  furnish  motion  and  sensation  to  the  upper  ex- 
tremities. 

"4.  The  fourth  set  includes  the  dorsal  nerves  from  the 
second  to  the  sixth.  This  supplies  the  chest  wall,  includ- 
ing the  pleura,  and  with  the  sympathetic  the  lungs 
beneath . 

"5.  The  fifth  set  consists  of  the  lower  seventh  to  elev- 
enth intercostals,  which  supply  motion  and  sensation  to 
the  abdominal  walls,  to  the  lower  dorsal  muscles,  and  the 
skin  over  them. 

"  6.  The  sixth  set  consists  of  the  first  four  lumbar 
nerves  with  part  of  the  twelfth  dorsal,  which  is  really  a 
lumbar  nerve.  This  supplies  motion  and  sensation  to,  in 
general  words,  the  hip  girdle — i.e.,  the  muscles  (erector 
spinse,  etc.)  of  the  loins,  those  of  the  anterior,  inner,  and 
outer  portion  of  the  thigh,  and  the  skin  over  these  regions, 
extending  down  to  the  upper  half  of  the  buttock  and  to 
the  groin,  scrotum,  and  labia.  It  is  the  lumbar  plexus 
which  furnishes  most  of  this  supply. 

"7.  The  seventh  and  last  set  consists  of  the  sacral 
nerves,  whose  anterior  branches  (those  of  the  first  four, 
with  the  lumbo-sacral  cord)  form  the  sacral  plexus.  This 
supplies  the  external  genitals  of  the  male,  the  clitoris  and 


THE    REFLEX    NEUEOSES. 


19 


,'__,  Decayed  lecdi. 


/]/f_^ 


Strands  of 
cerebrospinal 

Distribution. 

Associated 
ganglia  of 

Main  distribution. 

nerves. 

sympathetic. 

Area      I. 

Trigeminus, 
facial,  etc. 

Face  and  its  orifices, 
anterior  spalp. 

4  cerebral. 

Head. 

Area    II. 

Upper  4  cervi- 

Occipital    region, 

1st  cervical. 

Head    (slightly   to 

cal. 

neck. 

heart). 

Area  III. 

Lower  4  cervi- 
cal and  1st 
dorsal. 

Upper  extremities. 

2d  and  3d  cervi- 
cal, 1st  dorsal. 

Heart. 

Area  IV. 

Upper  6  dorsal. 

Thoracic  wall 

1st  to  6th  dorsal. 

Lungs. 

Area    V. 

Lower  6  dorsal 

Abdominal  wall,  up- 

5th to  12th  dor- 

Abdominal viscera, 

except  last. 

per  lumbar,  upper 
lateral    thigh    sur- 
face. 

sal. 

testes,  ovary, 
fundus  uteri  via 
renal  plexus. 

Area  VI. 

12th    dorsal,    4 

Lumbar   region,  up- 

1st to  4th  lum- 

Pelvic organs. 

lumbar. 

per  gluteal,    ante- 
rior and  inner  thigh 
and  knee. 

bar. 

Area  VII. 

5th  lumbar  and 

Lower   gluteal,  pos- 

1st to  5th  sacral. 

To    pelvic   organs, 

5  sacral. 

terior  thigh,  leg. 

the  sympathetic 
supply  being 
small. 

Figs.  1  and  S.— Diagram  showing  the  distribution  of  the  seven  cerebro-spinal 
strands  of  nerves,  and  the  location  of  transferred  pains  and  neui'algia.  (After 
Dana.) 


20  FUNCTIONAL   NERVOUS    DISORDEES. 

part  of  the  vagina,  the  perineum  and  external  sphincter 
and  the  lower  buttocks,  and  the  posterior  part  of  the  thigh 
and  leg,  except  its  inner  side.  In  a  general  way  we  may 
state  that  the  lower  portion  gives  motion  and  sensation  to 
the  legs  and  posterior  thigh  (the  sciatic) ;  the  upper  portion 
to  the  genitals  and  the  gluteal,  perineal,  and  anal  region 
(superior  gluteal,  small  sciatic,  pudic)/ 

*'  Now  each  of  these  seven  sets  of  nerves  is  in  intimate 
connection  by  two  branches  with  the  sympathetic  ganglia, 
and  through  these  with  the  viscera  of  the  different  cavities. 
The  accompanying  diagram  shows  better  than  any  descrip- 
tion what  this  relation  is. 

"  I.  The  first  two  leashes  of  nerves  are  connected  most 
intimately  with  the  four  cerebral  sympathetic  ganglia 
(ophthalmic,  otic,  submaxillary,  spheno-palatine)  and  with 
the  upper  cervical  ganglion. 

"  We  can  imderstand  how  irritations  in  the  cranial  cav- 
ity may  be  reflected  almost  indifferently  upon  the  trigemi- 
nal or  upper  cervical  nerves. 

"  II.  The  third  leash  of  nerves  to  the  upper  extremity  is 
connected  with  the  three  cervical  and  first  intercostal  gan- 
glia, all  of  which  go  to  make  up  the  cardiac  nerves. 

"  Hence  irritations  of  the  heart  are  reflected  so  often  in 
the  shoulder  and  down  the  arm. 

"  III.  The  first  six  nerves  of  the  thoracic  wall  are  con- 
nected with  the  corresponding  sympathetic  ganglia  which 
supply  the  lung  tissue,  and  this  anatomical  fact  may  ex- 
plain why  in  slight  pulmonary  congestions  pain  may  be  re- 
ferred to  the  intercostal  nerves. 


'  The  sides  of  the  body  and  both  upper  and  lower  extremities,  ex- 
cept a  portion  of  tlie  legs,  are  supplied  b}^  lateral  branches  of  the 
spinal  nerves ;  the  back,  from  occiput  to  iliac  crest,  by  dorsal 
branches. 


THE    REFLEX    NEUROSES.  21 

"  IV.  The  fifth  leash  of  nerves,  fifth  to  the  eleventh  in- 
tercostal, is  connected  with  the  sympathetic  ganglia,  which 
supply  nerves  to  the  abdominal  viscera  via  the  splanchnic 
nerves.     The  great  splanchnic  supplies  all  the  abdominal 


Fig.  3.— Chart  Showing  the  Different  Levels  of  the  Cerebro-spinal  and  Sympathetic 
Nerve-supply.  Cerebro-spinal  nerves  represented  on  the  right  side  ;  sympathetic 
nerves  on  the  left  side.    (After  Dana.) 

viscera,  including  the  visceral  serous  membranes,  except 
the  kidneys.  These  are  more  largely  supplied  by  the  small 
splanchnic  which  arises  from  the  eleventh  and  twelfth 
thoracic  ganglia.     The  renal  plexus  in  turn  sends  branches 


22  FUNCTIONAL   NERVOUS    DISORDEES. 

to  the  spermatic  cord,  testes,  ovary,  and  fundus  uteri,  so 
that  those  parts  of  the  pelvic  organs  are  especially  con- 
nected with  the  lower  dorsal  nerves ;  hence  irritations  of 
ovary,  testes,  cord,  part  of  the  uterus  and  kidneys,  are 
often  reflected  as  pains  in  the  region  of  the  kidneys  and  in 
the  groins.  It  is,  perhaps,  over  this  arc  that  the  low-down 
one-sided  pains  so  often  felt  over  the  ninth  to  twelfth  ribs 
originate, 

"  V.  The  lumbar  strand  of  nerves  is  connected  with  the 
lumbar  ganglia  and  via  the  aortic  plexus  with  the  descend- 
ing colon,  sigmoid  flexure,  and  upper  part  of  the  rectum ; 
through  the  hypogastric  plexus  with  the  pelvic  organs 
which  it  joins  the  sacral  nerves  and  ganglia  in  supplying. 

"VI.  The  genital  organs  (vagina,  cervix  uteri,  penis, 
prostate),  except  the  testes  and  ovaries,  are  in  close  con- 
nection with  the  sacral  strand  of  nerves  (the  seventh) ;  the 
other  pelvic  viscera  are  more  abundantly  supplied  by  the 
lumbar  and  lower  dorsal  strands.  Hence  we  find  sciaticas 
and  podalgia,  and  reflex  pains  throughout  the  lower  ex- 
tremity in  urethral  irritations,  rarely  in  irritations  of  the 
testes,  ovary,  or  higher  parts  of  the  pelvis.  These  latter 
cause  more  often  lumbo-abdominal  neuralgias. 

"  In  attempting  to  explain  the  reflex  pains  from  the  vis- 
cera, I  am  led  to  the  belief  that  the  pneumogastric  nerve 
must  be  left  out  of  account  as  a  direct  factor.  The  mass 
of  the  sympathetic  nerves  to  the  sensitive  thoracic,  ab- 
dominal, and  pelvic  viscera,  are  made  up  of  white,  medul- 
lated  nerves  that  come  directly  from  the  cord.  These 
nerves  carry  sensory  fibres,  and  their  excitation  is  painful 
(Ludwig,  O.  Nasse). 

"  Whether  it  be  the  heart,  stomach,  or  uterus,  therefore, 
irritations  that  excite  pain  more  probably  pass  up  to  the 
brain  via  the  spinal  nerves,  their  posterior  roots,  and  the 


THE    REFLEX    XEUROSES.  33 

spinal  cord.  Having,  however,  to  travel  through  two  or 
three  sets  of  ganglia,  it  is  easy  to  understand  how  they 
may  become  diffused,  and  travel  up  paths  belonging  to 
another  strand  of  nerves,  and  so  be  referred  by  the  mind 
to  a  place  remote  from  their  origin. " 

I  have  taken  the  liberty  of  quoting  very  extensively  from 
Dr.  Dana's  article  on  account  of  its  great  value  in  the 
elucidation  of  the  subject. 

Sometimes  transferred  pains  are  of  organic  origin  and 
due  to  the  effects  of  pressure.  This  is  illustrated  in  the 
following  case  reported  by  Dr.  John  Hilton : 

"  Within  the  last  three  months  I  was  requested  to  see  a 
young  lady  from  the  country  on  account  of  some  painful 
symptoms  she  had  in  her  right  hand,  especiallj'' in  the  little 
finger  and  the  ring  finger.  Associated  with  these  symp- 
toms there  was  the  suspicion  of  an  aneurism  of  the  right 
subclavian  artery.  I  will  not  trouble  you  with  all  the 
particulars  of  this  case,  but  only  those  which  bear  upon 
the  suggestions  before  us.  The  patient  had  a  slight,  hard 
swelling  upon  the  first  rib,  which  her  mother  thought  had 
resulted  from  a  fracture  that  occurred  in  her  childhood, 
she  being  now  about  nineteen  years  of  age.  The  swelling 
had  lifted  wp  the  subclavian  artery  very  much,  and  gave 
it  the  appearance  of  unusual  pulsation,  and  upon  close  ex- 
amination a  sort  of  aneurismal  bruit  could  be  heard,  ap- 
parently the  result  of  some  enlargement  encroaching  upon 
the  subclavian  artery.  There  was  really  no  aneurism. 
This  was  a  case  in  point,  where  something  had  occurred 
to  the  first  rib,  possibly  a  fracture  (of  that  I  have  my 
doubts,  still  it  might  have  been  so),  which  led  to  the  pres- 
sure upon  this  ulnar  nerve,  and  had  caused  the  loss  of  sen- 
sation in  the  little  and  the  adjoining  finger,  the  loss  of  tem- 
perature in  those  two  fingers  especialh',  and  ver}^  constant 
pain  in  them.  These  are,  as  far  as  I  can  see,  conditions  of 
a  case,  which  might  ultimately  terminate  in  gangrene  of 
the  fingers.     In  the  case  of  this  young  lady,  we  have  only 


24  FUXCTIOXAL   XERYOUS   DISORD EES. 

the  evidence  of  deterioration  having  gone  so  far  as  to 
diminish  both  the  size  and  the  temperature  of  the  fingers, 
and  to  produce  considerable  pain  in  them.  What  has  been 
the  issue  of  the  case  I  do  not  know.  It  was,  before  I  saw 
it,  invested  with  a  great  degree  of  anxiety,  on  the  part  of 
both  the  patient  and  her  friends,  for  they  had  received  the 
impression  that  she  had  a  subclavian  aneurism,  which 
would  require  a  very  serious,  and  no  doubt  to  her  mind  a 
very  dangerous,  operation." 

The  following  case,  also  reported  b}^  Hilton,  shows  the 
effect  of  transferred  irritations  in  modifying  the  nutrition 
of  a  part : 

"  Gray  Hair  on  the  Temple  Depending  on  a  Decayed 
Molar  Tooth  in  the  Loiver  Jaw  on  the  Same  Side. — 
A  person  was  brought  to  me  by  a  surgeon  suffering  very 
great  pain  on  the  left  side  of  his  face.  He  was  much  ex- 
posed to  the  weather,  and  suffered  a  great  deal  in  conse- 
quence. He  had  taken  many  things  to  cure  the  neuralgia, 
as  it  was  termed.  I  observed  that  he  wore  a  wig,  and  I 
asked  him  the  reason.  He  said,  'Curiously  enough,  the 
hair  on  my  left  temple  has  all  turned  gray.  I  did  not  like 
to  have  black  hair  on  one  side  and  gray  on  the  other,  so  I 
had  my  head  shaved,  and  wear  a  w^ig. '  Upon  examining 
his  mouth,  I  found  he  had  a  decaj'ed  and  painful  molar 
tooth  on  the  left  side  of  the  lower  jaw — supplied  by  the 
third  division  of  the  fifth  nerve.  The  patch  of  gray  hair 
appeared  to  me  to  be  the  effect  of  the  nervous  association 
of  the  auriculo-temporal  branch  of  this  third  division  of  the 
fifth  nerve  with  the  decayed  tooth  in  the  lower  jaw. 
When  this  second  molar  tooth  in  the  lower  jaw  was  ex- 
tracted the  neuralgic  pain  very  nearly  ceased.  I  have  not 
seen  the  patient  since,  and  cannot  say  whether  the  hair 
has  recovered  its  color.  All  I  can  say  is,  it  was  stated  to 
me,  that  during  the  time  he  was  suffering  extreme  pain  on 
the  left  side  the  hair  over  the  temporal  region  became 
nearly  white:  a  difference  in  color  suggesting  to  myself 
some  structural  deterioration,  and  to  the  patient  the  pro- 
priety of  having  his  head  shaved  and  wearing  a  wig." 


THE    KEFLEX    NEUROSES.  25 

The  curious  effect  that  fright  and  pain  or  neuralgia  in 
a  distant  part  has  in  causing  the  hair  to  turn  gray  sud- 
denly has  been  exemplified  lately  in  my  practice.  Ten 
days  ago  I  was  asked  to  see  Mrs.  K.,  a  lady  of  sixty-five 
years  who  had  been  knocked  down  by  a  cable  car.  The 
only  injury  she  received  besides  a  very  great  fright  and  a 
severe  bruising  was  a  painful  injury  to  the  back  of  the  left 
hand.  The  daily  dressing  of  the  hand  was  performed  by 
my  assistant,  who,  like  many  other  recent  hospital  and  dis- 
pensary graduates,  was  not  at  all  tender  or  sympathetic  in 
his  manipulation;  moreover,  the  solution  of  bichloride 
of  mercury  and  the  mixture  of  ether  and  iodoform  applied 
was  an  additional  source  of  pain.  The  family  and  the 
friends  of  the  patient  state  emphatically  that  before  the 
accident  she  did  not  have  a  gray  hair  in  her  head.  Now 
the  vertex  and  frontal  region  is  quite  gray,  the  black  and 
gray  lying  peculiarl}"  in  streaks.  On  the  left  side,  the 
same  side  as  the  injured  hand,  the  hair  is  very  much 
grayer  and  covers  a  much  larger  surface,  extending  down 
on  the  side  of  the  head  much  farther  toward  the  neck. 
The  hair  on  the  back  of  the  head  and  neck  is  very  black. 
It  has  always  been  heretofore  a  subject  of  interest  and  re- 
mark to  the  family  and  friends  that  although  sixty-five 
years  old,  Mrs.  K.  was  entirely  without  any  gray  hairs. 

Another  case  with  which  I  am  acquainted  is  that  of  a 
young  man  whose  wife  was  drowned  in  a  freshet,  where 
she  was  found  among  a  lot  of  bushes.  Her  appearance 
was  so  terrible  and  the  sight  gave  the  husband  such 
a  shock  that  the  hair  of  part  of  one  side  of  his  head 
and  the  eyebrow  and  corresponding  half  of  his  mus- 
tache turned  perfectly  white.  These  sudden  modifica- 
tions of  nutrition  of  a  part  are  difficult  to  explain,  espe- 
cially so  when  we  consider  the  hair  simply  as  an  appen- 


26  FUNCTIONAL    NERVOUS    DISORDERS. 

dage  to  the  body.  Cases  of  sudden  fright  turning  all  the 
hair  white  in  a  single  night  are  often  reported.  Mr.  R.  S., 
when  a  young  man,  was  shipwrecked  and  floated  in  the 
ocean  for  forty-eight  hours  lashed  to  a  plank.  When 
found  his  hair  had  turned  very  white  as  a  result  of  the 
mental  agony  which  he  had  undergone. 


CHAPTER    II. 

THE  CEREBRAL  NEUROSES   OR  PSYCHOSES. 

There  are  peculiarities  of  the  mind  well  known  to  every 
observer,  which  are  often  dependent  upon  morbid  con- 
ditions of  the  abdominal  and  pelvic  viscera.  Of  these  the 
lighter  and  more  common  forms  are :  Mental  depression, 
loss  of  memory,  excessive  irritability,  wakefulness,  or,  on 
the  other  hand,  intense  lethargy  and  drowsiness  during 
the  daytime;  morbid  fears,  such  as  of  death,  disaster, 
or  insanity;  hypnotism,  trance,  catalepsy,  somnambu- 
lism, neurasthenia  or  nervous  exhaustion,  anaesthesias, 
globus  hystericus,  cardiac  palpitations,  joint  neuroses  or 
joint  pains,  amenorrhoea,  enuresis,  dyspepsia,  and  diar- 
rhoea coming  on  from  bad  news  or  "hard  times."  Under 
this  head  will  come  all  the  hysterical  symptoms  dependent 
upon  the  emotions,  such  as  hj'sterical  aphonia,  hysterical 
apnoea,  hj^sterical  laryngismus,  hysterical  suffocation  and 
strangulation.  The  more  severe  types  are  melancholia, 
mania,  and  convulsions. 

It  is  not  to  be  expected  that  we  have  included  all  the 
cerebral  neuroses,  but  we  will  simply  touch  upon  the  more 
prominent  and  those  most  frequently  met  with.  The 
question  in  my  mind  is,  how  to  differentiate  hysteria,  which 
is  generally  dependent  upon  anaemia,  from  the  neuroses. 
The  cerebral  neuroses  often  occur  in  neurotics  from  the 
mind  being  directed  to  a  particular  part;  this  is  seen  in 
patients  who  are  familiarly  known  as  "  womb  cranks, "  who 

imagine  they  have  uterine  disease,   and  are   sometimes 

27 


28  FUNCTIOlSrAL   ]SrEEVOUS    DIS0KDEE8. 

readily  cured  by  almost  any  simple  manipulation  of  the 
uterus.  Many  of  these  women  have  been  cured  by  having 
a  uterus  "  tipped  into  place"  when  it  was  never  out  of  its 
normal  position,  while  in  others,  local  measures  of  any  kind 
will  not  avail  for  the  cure  of  the  mental  disorder. 

The  influence  of  the  digestive  and  sexual  organs  upon 
the  mental  functions  is  well  known  to  all  physicians,  yet 
in  the  practical  treatment  this  knowledge  is  not  always 
used  to  advantage.  A  young  woman  of  exceedingly  happy 
disposition  becomes  despondent  and  discouraged,  with  a 
completely  changed  disposition.  From  being  kind  and 
agreeable  she  becomes  offensive,  peevish,  and  insulting. 
This  mental  state  is  the  result  of  an  exacerbation  of  diges- 
tive or  uterine  disease,  and  is  in  reality  a  reflex  hystero-  or 
gastric  psychosis.  In  some  cases  it  is  so  severe  as  to  cause 
fixed  delusions ;  even  in  the  milder  forms  these  psychoses 
result  in  much  domestic  unhappiness. 

The  psycho-neuroses  such  as  melancholia,  mania,  and 
hysterical  insanity,  which  are  not  in  any  way  connected 
with  organic  disease  of  the  cerebrum,  are  often  benefited 
by  operations  and  treatment  directed  to  other  organs  of  the 
body.  Interesting  cases  in  confirmation  of  this  have  been 
recorded  by  Dr.  Fordyce  Barker  and  other  authorities. 

Very  much  can  be  done  in  the  way  of  improving  these 
functional  disorders  by  the  method  of  expectant  attention. 
If  the  patients  are  thoroughly  convinced  that  the  physician 
is  curing  them,  many  of  them  readily  get  well  under  almost 
any  form  of  treatment,  but  there  can  be  no  doubt,  as  every 
gynaecologist  is  well  aware,  that  many  neuroses  of  a  severe 
character  depend  upon  uterine  and  ovarian  lesions  which 
must  receive  attention.  In  puerperal  mania  and  melan- 
cholia nothing  favors  the  return  of  the  mental  faculties 
to  the  normal  so  much  as  the  restoration   to   health  of 


THE    CEREBRAL    XEUROSES    OR    PSYCHOSES,  29 

the  pelvic  viscera.  Uterine  involution  will  often  start  im- 
provement. 

A  common  time  for  cerebral  neuroses  or  psychoses  to  ori- 
ginate is  the  first  few  weeks  of  married  life.  I  have  seen 
the  worst  cases  of  hysterical  apnoea  dependent  on  a  cica- 
trized lacerated  cervix.  Severe  migraine  resulting  from 
ovarian  inflammation  or  from  indigestion  is  a  most  com- 
mon occurrence. 

The  following  case  is  instructive  in  this  connection : 

Migraine,  Hemiplegia,  and  Chorea,  Dependent  upon 
Uterine  Irritation. — Mrs.  Alice  C,  set.  18  years;  menses 
came  on  first  profusely  when  she  was  13,  lasting  for  four 
or  five  days.  During  her  sixteenth  year  they  became 
very  scanty,  lasting  two  days.  This  condition  continued 
for  about  six  months  when  severe  pain  of  short  duration 
started  in  the  left  ovarian  region.  Then,  from  overwork 
and  worry  followed  by  a  mild  attack  of  diphtheria,  her 
present  condition  was  developed.  She  suffered  severely 
from  chorea  and  was  also  very  hysterical.  The  hemiplegia 
came  on  gradually  six  weeks  after  the  attack  of  diphtheria, 
and  involved  the  face  and  upper  and  lower  extremity  of 
the  left  side.  The  attack  of  hemiplegia  lasted  for  three 
months.  She  was  treated  by  medication  and  actual 
cautery  applied  to  the  back.  The  treatment  helped  the 
chorea  but  had  no  effect  on  the  hemiplegia.  There  were 
no  changes  at  this  time  in  the  menses,  which  were  still 
scanty  and  painful.  At  the  end  of  three  months  she  took 
a  short  sea  voyage  (as  far  as  Portland,  Me.),  which  caused 
a  complete  disappearance  of  hemiplegia  and  chorea.  About 
a  month  afterward,  after  a  thirty-mile  ride  and  a  severe 
disappointment  in  a  love  affair,  she  had  a  slight  return  of 
the  hemiplegia.  Two  months  later,  on  her  return  to  the 
city  during  the  hot  weather,  she  had  a  severe  attack  of 
right  hemiplegia.  She  at  present  complains  of  occipital 
and  temporal  headaches.  There  is  also  severe  pain  in  the 
cardiac  region.     Has  had  nasal  hemorrhages  at  time  of 


30  FUNCTION-AL    NERVOUS    DISORDERS. 

menses  for  several  months  and  at  other  irregular  periods. 
For  the  last  few  days  she  has  suffered  from  nausea  and 
morning  vomiting ;  is  now  pregnant. 

The  hemiplegia  continues  on  the  right  side ;  its  seat  was 
formerly  the  left.  She  is  excessively  nervous;  her  tongue 
seems  to  he  thick  and  her  speech  is  imperfect.  Any  se- 
vere annoyance  will  cause  a  fit  of  hysteria.  Suffers  also 
with  migraine  on  the  left  side  accompanying  the  morning 
vomiting. 

The  functional  character  of  the  hemiplegia  in  the  pre- 
ceding case  is  shown  not  only  by  its  transference  from  the 
left  to  the  right  side,  but  also  in  a  degree  by  its  occur- 
ring at  an  early  age,  organic  hemiplegia  or  paraplegia 
occurring  usually  at  an  advanced  age  or  at  the  time  of 
degenerative  changes  in  the  blood-vessels.  Like  chorea, 
functional  hemiplegia  is  found  during  periods  of  develop- 
ment. 

Fimctional  Paralyses. — There  are  many  points  of  simi- 
larity in  functional  and  organic  palsies;  it  is,  however, 
often  easy  to  differentiate  between  the  two.  The  functional 
variety  is  generally  connected  with  the  menstrual  period 
and  exaggerated  by  it,  its  intensity  varying  from  time  to 
time.  These  paralyses  sometimes  disappear  suddenly, 
although  as  a  rule  the  return  to  the  normal  condition  is 
gradual. 

In  speaking  of  functional  and  hysterical  paralyses  we 
should  carefully  differentiate  between  the  two,  calling  only 
those  bj^sterical  in  which  the  emotions  play  a  part.  The 
term  hysteria  ought  to  be  confined  to  cases  where  distinc- 
tive hysterical  symptoms  are  present,  as  there  are  many 
functional  cases  without  apparent  hysteria.  In  these  cases, 
if  we  begin  by  rectifying  the  general  health,  the  mind  will 
of  itself  return  to  the  normal  state.  If  the  intelligence  and 
will  power  of  the  patient  are  enlisted  in  the  treatment  and 


THE    CEREBRAL    NEUROSES    OR    PSYCHOSES. 


31 


she  uses  them  to  help  herself,  the  recovery  is  much  more 
rapid. 

Muscular  power  is  greatly  diminished  in  hysterical 
cases.  This  is  most  pronounced  in  the  extremities,  espe- 
cially on  the  left  side. 

When  facial  palsy  is  present  it  is  generally  on  the  side 


Fig.  4.— Hysterical  Paralysis. 


FiGf.  5.— Hysterical  Contracture. 


Fig.  6.— Crutch  Paralysis.  Fig.  7. — Crutch  Paralysis. 

From  a  Patient  Falling  Asleep  with  Axilla  Resting  on  the  Back  of  a  Chair. 


of  the  involved  limbs.  Aphonia,  due  to  palsies  of  the 
laryngeal  muscles,  is  quite  common,  and  the  muscles  of 
the   pharynx   and   oesophagus  have  also  been   noted   by 


33  FUNCTIOJSTAL   NERVOUS    DISORDERS. 

many  observers  as  having  been  affected  with  hysterical 
paralysis. 

In  the  common  forms  of  this  disorder  one  limb,  one  side, 
or  both  lower  extremities  are  involved.  The  attacks  usually 
come  on  after  severe  mental  excitement  or  a  hystero-epi- 
leptic  seizure.  The  paralysis  may  be  partial  or  complete, 
and  is  usually  accompanied  by  anaesthesia. 

Vesical  paralysis  is  very  frequently  present  in  cases  of 
hemiplegia  and  paraplegia,  but  rectal  paralysis  is  much 
less  common. 

Anaemic  or  functional  paralysis  depends  upon  qualitative 
changes  in  the  blood  and  is  often  the  result  of  severe  dis- 
eases. The  red  blood  corpuscles  are  diminished  and  the 
watery  elements  increased,  with  the  result  of  affecting  the 
motor  functions  of  the  nerve  centres. 

Functional  or  anaemic  paralysis  has  been  seen  after  such 
exhausting  diseases  as  typhoid  fever,  chronic  diarrhoea  or 
dysentery,  bowel  and  uterine  hemorrhages,  chlorosis,  dia- 
betes, scurvy,  and  malaria.  Even  in  intestinal  indigestion 
there  is  excessive  weakness  of  the  lower  extremities  accom- 
panied by  cramps  and  pain.  The  paraplegia  in  these  cases 
is  due  to  a  lack  of  arterial  blood  in  the  spinal  cord.  We 
should  be  careful  to  differentiate  between  functional  and 
organic  paralyses,  such  as  come  on  from  the  arterial 
changes  in  syphilis  or  from  embolism.  The  digestive  tract 
and  genito-urinary  organs  are  generally  the  exciting 
factors,  when  diseased,  of  the  functional  or  reflex  paralysis. 
The  irritation  arising  in  these  organs  causes  a  contraction 
of  the  blood-vessels  of  the  spinal  cord  which  may  lead 
eventually  to  an  atrophy  of  the  parts  involved.  Excessive 
irritation  of  the  sensory  fibres  causes  an  arrest  of  the 
functions  of  the  motor  nerve  centres.  On  careful  exami- 
nation many  of  the  so-called  reflex  or  functional  paralyses 


THE    CEEEBRAL   NEUROSES    OR    PSYCHOSES.  33 

will  be  found  due  to  pathological  changes  in  the  spinal 
cord. 

Echeverria  reports  a  case  of  ulceration  of  the  cervix  uteri, 
in  which  the  application  of  a  weak  galvanic  current,  one 
electrode  upon  the  symphysis  pubis  and  the  other  upon  the 
uterine  cervix,  produced  violent  pain  and  trembling  in  the 
legs,  with  paralysis  for  fourteen  hours. 

Rosenthal  reports  a  case  of  a  girl,  aged  twenty-three,  who 
suffered  for  three  weeks  from  paresis  of  the  legs  coming 
on  with  pains  and  cramps  in  the  abdomen.  He  found 
a  needle  deeply  embedded  in  the  vagina,  and  after  its  re- 
moval the  paresis  disappeared  rapidly. 

In  Nonat's  case,  loss  of  consciousness  with  paraplegia 
came  on  as  the  result  of  cauterization  of  the  uterine 
cervix. 

Landry  reports  a  case  in  which  the  paralysis  disap- 
peared after  the  restoration  of  the  deflected  uterus  to  its 
normal  position. 

The  most  common  cause  of  functional  paraplegia  is  irri- 
tation of  the  genital  organs  by  masturbation  or  excessive 
venery.  When  from  excessive  coition,  the  paralysis  comes 
on  very  suddenly. 


CHAPTER   III. 
SPINAL  REFLEX  NEUROSES. 

Changes  in  the  uterus  and  dig^estive  tract  manifest  them- 
selves by  irritations  throughout  the  whole  of  the  spinal 
column,  and  in  fact  throughout  the  entire  nervous  system, 
and  by  the  spinal  and  cerebral  nerves  all  portions  of  the 
body  respond  to  these  changes.  Many  of  the  sj^mptoms 
arising  are  readily  noted  by  the  laity :  pains  in  the  wrists, 
ankles,  and  fingers  are  often  called  wind  pains,  resulting 
as  they  sometimes  do  from  irritations  in  the  digestive  tract 
when  flatulence  is  present. 

Spinal  irritation  and  spinal  pains  are  quite  character- 
istic of  uterine  disease,  and  the  backache  of  weak  diges- 
tion is  a  very  common  sj^mptom.  For  a  good  example  of 
spinal  neurosis  the  case  of  Miss  M.  N.,  page  233,  may  be 
cited. 

Sympathetic  pains  occurring  on  the  surface  of  the  body, 
and  having  connection  with  affections  of  internal  organs, 
are  of  great  interest,  as  by  them  we  can  appreciate  and 
locate  organic  changes  and  derangements  of  function  of 
the  internal  portions  of  the  body. 

The  pain  which  occurs  between  the  shoulders  or  over  the 

inferior  angles  of  the  scapula  is  perhaps  the  most  frequent 

of  these  "sympathetic"  pains  which  we  meet,  and  must 

be  connected  with  the  distribution  of  some  of  the  spinal 

nerves,  because  there  are  no  other  structures  which  could 

give  expression  to  the  pain,  and  no  other  nerves  occupy  this 

position  except  the  fourth,  fifth,  and  sixth  dorsal  nerves, 

34 


SPIN"AL   KEFLEX    NEUROSES.  35 

which  are  distributed  over  the  interscapular  space  and  the 
inferior  angles  of  the  scapulae. 

Hilton  says :  If  we  trace  the  great  splanchnic  nerve  from 
within  the  thorax  downward,  and  find  it  connected  at  its 
abdominal  end  with  the  solar  plexus,  thence  trace  its  dis- 
tribution to  the  stomach,  duodenum,  liver,  and  pancreas; 
and  if  we  follow  the  other  or  upper  end  of  the  same  great 
splanchnic  upward  to  the  fourth,  fifth,  and  sixth  dorsal 
nerves,  which  give  peripheral  sensitive  filaments  to  the  in- 
teguments, over  the  angles  of  the  scapulse,  to  the  interscapu- 
lar spaces  and  the  adjoining  skin,  one  can  well  imagine  that 
these  nerves  carrying  the  influence  upward  and  backward 
may  explain  the  occurrence  of  the  pains  sometimes  expe- 
rienced in  those  external  parts  associated  with  abdominal 
visceral  disturbance.  The  pain  which  persons  experience 
in  disease  of  these  viscera  may  be  explained  by  the  relative 
position  of  the  great  splanchnic  nerve,  communciating,  on 
the  one  hand,  with  the  solar  plexus,  and  then  with  these 
digestive  organs,  and,  on  the  other,  distributing  its 
branches  to  the  fourth,  fifth,  and  sixth  dorsal  nerves. 

In  disease  of  the  lower  cervical,  the  dorsal,  and  the 
lumbar  regions  of  the  vertebral  column  the  pain  is  usually 
expressed  on  both  sides  symmetrically.  When  the  dis- 
ease lies  between  the  occiput  and  the  atlas,  or  between  the 
first  and  second  cervical  vertebrae,  this  is  not  the  case.  In 
all  cases  of  symmetrical  pain  the  cause  is  central,  or  double, 
both  sides  being  alike  in  a  diseased  condition. 

For  instance,  the  positions  of  the  sixth  and  seventh  dorsal 
nerves  are  here  indicated,  as  they  are  distributed  to  the 
skin  just  over  the  pit  of  the  stomach.  If  pain  be  felt  at 
that  part  alike  on  both  sides  of  the  median  line,  these 
nerves  become  the  only  possible  expression  of  that  cause, 
for  there  is  no  other  structure  there  situated  which  could 


36 


PU2^"CTI0]SrAL   JSTEEVOUS   DISOKDERS. 


manifest  the  pain.  Then,  tracing  the  nerves  producing 
these  surface  pains  backward  to  the  posterior  median  line, 
and  noting  accurately  the  healthy  or  unhealthy  condition 
of  the  various  structures  near  which  these  intercostal  nerves 
would  pass — such  as  the  ribs,  pleurge,  aorta,  oesophagus, 
and  other  structures  in  the  poste- 
rior mediastinum — we  arrive  at 
the  vertebra  and  spinal  cord,  and 
in  that  way,  by  the  law  of  exclu- 
sion, we  arrive  at  the  diseased 
spine  as  the  real  cause  of  the  pains 
experienced  at  the  pit  of  the  stom- 
ach (see  Fig.  8). 

In  children  bellyache  is  often 
the  most  prominent  symptom  in 
pleurisy  or  pneumonia.  The  at- 
tendant often  concentrates  his 
attention  entirely  upon  the  viscera 
under  the  upper  half  of  the  ab- 
dominal walls.  This  treatment  is 
entirely  misplaced,  and  blistering 
or  poulticing  the  chest  is  the 
This  is  also  an  instance  where  the 
same  nerves  which  supply  the  muscles  supply  likewise  the 
skin  over  the  muscles,  and  where  the  local  manifestations 
are  remote  from  the  real  cause  of  the  symptoms. 

The  Griffin  brothers,  of  Limerick,  in  their  exhaustive 
and  valuable  work  entitled  "  Observations  on  the  Functional 
Affections  of  the  Spinal  Cord  and  Ganglionic  Nerves,  in 
which  their  Identity  with  Sympathetic,  Nervous,  and 
Simulated  Disease  is  Illustrated,"  published  sixty  years 
ago  in  London,  draw  the  following  conclusions : 

"  1st.  That  tenderness  at  one  or  more  points  of  the  spine 


Fig.  8.— Side  View  of  Chest, 
Showing  the  Course  of  the 
Sixth  and  Seventh  Dorsal 
Nerves.    (Hilton.) 

method  to  be  pursued. 


SPINAL   KEFLEX    NEUROSES.  37 

is  an  attendant  on  almost  all  hysterical  complaints,  on 
numerous  cases  of  functional  disorder  when  the  hysteric 
disposition  is  not  so  obvious,  and  in  many  nervous  or  neu- 
ralgic affections. 

"2d.  That  many  of  the  symptoms  of  these  affections 
evidently  depend  upon  a  peculiar  state  of  certain  nerves, 
probably  at  their  origin,  may  be  reproduced  at  any  moment 
by  pressure,  and  are  often  relieved  by  remedies  applied 
there. 

"  3d.  That,  in  all  cases  of  tenderness  of  the  cervical  and 
upper  dorsal  spine,  there  was  nausea,  or  vomiting,  or  pain 
of  the  stomach,  or  affections  of  the  upper  extremities;  but 
no  pain  of  the  abdomen,  dysuria,  ischuria,  hysteralgia,  or 
affections  of  the  lower  extremities. 

"4th.  That,  in  all  cases  of  dorsal  tenderness,  pains  affect- 
ing the  abdomen,  bladder,  uterus,  testes,  or  lower  extrem- 
ities, were  usual  symptoms;  while  nausea,  vomiting,  or 
affections  of  the  upper  extremities  were  never  complained 
of. 

"  5th.  That  nausea  and  vomiting  appeared  to  have  more 
relation  to  tenderness  of  the  cervical  spine,  pain  of  the  stom- 
ach to  tenderness  of  dorsal;  but  that,  when  there  was  sore- 
ness of  both,  nausea  or  vomiting  was  still  more  frequent, 
and  pain  of  the  stomach  scarcely  ever  absent. 

"  6th.  That  when  several  points  or  a  great  extent  of  the 
spinal  column  are  painful  and  tender  on  pressure,  local 
remedies  are  generally  less  effectual,  and  there  is  a  strong 
disposition  to  transference  of  the  disordered  action  from 
one  organ  to  another ;  the  pain  or  tenderness  in  all  such 
cases  of  transference  shifting  its  place  to  a  corresponding 
part  of  the  spinal  column,  leaving  the  original  point  free, 
or  with  a  very  diminished  degree  of  tenderness. 

"  7th.  That  spinal  tenderness  is  seldom  or  never  met  with 


38  FUlSrCTIONAL   NER70US   DISOEDBRS. 

in  cases  of  pure  inflammation,  except  when  these  accident- 
ally occur  in  persons  previously  suffering  from  irritation 
of  the  cord;  and  that,  when  appearances  of  inflammation 
present  themselves  in  any  organ,  accompanied  by  a  corre- 
sponding spinal  tenderness,  they  cannot  commonly  be  re- 
moved by  the  remedies  applicable  to  inflammatory  cases, 
and  are  often  rendered  worse  by  them. 

"  8th.  That  there  does  not  appear  to  be  a  complaint  to 
which  the  human  frame  is  liable,  whether  inflammatory  or 
otherwise,  which  may  not  be  occasionally  imitated  in  dis- 
turbed states  of  the  cord;  and  hence  that  this  disturbed 
state  is  one  vast  source  of  those  complaints  called  hysterical 
or  nervous. 

"  9th.  That  those  functional  disorders  connected  with 
spinal  tenderness  are  very  often  attended  by  some  disturb- 
ance of  the  functions  of  the  uterus,  but  that  they  are  by 
no  means  always  so,  since  they  occur  in  those  who  are 
regular  in  this  respect ;  in  girls  long  before  the  menstrual 
period  of  life,  in  women  after  it  has  passed,  and,  lastly,  in 
men  of  nervous  susceptible  habits,  and  in  boys. 

"  10th.  That  in  fact  they  are  not  necessarily  dependent 
upon  any  one  organ ;  since  they  are  found  indifferently 
coexisting  with  disturbance  of  the  digestive  organs  solely, 
or  the  uterus  solely,  or  of  the  circulatory  or  respiratory 
system. 

"  11th.  That  from  the  cases  detailed  we  have  reason  to 
suppose  spinal  tenderness  may  arise  from  uterine  disorders, 
from  dyspepsia,  from  worms  in  the  alimentary  passages, 
from  affections  of  the  liver,  from  mental  emotions,  from 
the  poison  of  typhus,  from  marsh  miasmata,  from  erysip- 
elatous, rheumatic,  and  eruptive  fe^'ers,  and  from  the  irri- 
tation arising  from  local  injury. 

"  12th.  That  it  is  almost  invariably  found  in  connection 


SPIKAL   KEFLEX    NEUROSES.  39 

with  gastric  or  abdominal  tenderness,  in  fever ;  and  this 
tenderness  is  probably  like  the  soreness  of  the  scalp,  pains 
in  the  limbs,  etc.,  dependent  on  a  morbid  state  of  the  cord. 

"  13th.  That,  whether  in  fever  or  in  other  complaints,  it 
is  met  with  in  the  situation  of  the  eighth  or  ninth  dorsal 
vertebra  much  more  frequently  than  at  any  other  part  of 
the  spine. 

"  14th.  That  affections  attended  by  spinal  tenderness  are 
seldom  fatal ;  that,  even  in  those  cases  of  intense  irritation 
of  the  cord  under  which  patients  suffer  extremely  from 
pain  for  years,  the  event  is  generally  favorable. 

"  15th.  That  they  frequently,  as  well  as  hysteria,  occur 
with  all  the  appearances  of  a  primary  affection  of  the 
nervous  system. 

"  1 6th .  That  affections  are  occasionally  met  with  present- 
ing all  the  marks  of  the  hysteric  character,  and  perfectly 
resembling  cases  described  as  those  of  spinal  irritation,  but 
unattended  by  spinal  tenderness  or  any  other  direct  indi- 
cation of  a  morbid  state  of  the  cord." 

In  one  form  of  spinal  irritation  the  hypersesthetic  or 
hypersemic  type  predominates ;  this  is  especially  frequent  in 
women.  One  of  the  first  signs  of  the  disease  is  weakness 
and  weariness  of  the  back  and  limbs.  There  is  pain  in  the 
back,  which  is  intermittent  at  first  but  afterward  becomes 
very  severe  and  constant ;  it  is  usually  located  in  the  neck 
or  between  the  scapulae;  it  occurs  less  commonly  lower 
down.  The  spinal  column  is  extremely  sensitive  to  pres- 
sure, the  pain  is  increased  by  exertion,  by  sitting  erect  or 
by  bending  of  the  body;  from  the  irritated  spine  the  pain 
radiates  in  all  directions  according  to  that  portion  of  the 
column  which  is  affected.  When  the  upper  portion  is  in- 
volved, there  is  headache,  insomnia,  vertigo,  nausea  and 
vomiting,  dyspnoea,  palpitation  of  the  heart,  irritation  of 


40  FUNCTIONAL   NERVOUS    DISORDERS. 

the  diaphragm  causing  hiccough,  heaviness,  and  soreness  of 
the  upper  extremities.  When  it  is  the  lower  portion  which 
is  involved  the  abdomen,  uterus,  and  bladder  are  affected 
by  spasms  and  neuralgias ;  the  lower  extremities  are  often 
weak  and  cold.  These  neuralgias  and  motor  disturbances 
are  often  of  a  migratory  character.  Along  with  the  head- 
ache there  is  mental  weakness;  the  patient  quickly  tires  of 
intellectual  effort.  It  is  a  chronic  ailment  lasting  many 
weeks  or  months,  the  patient  alternately  improving  and 
relapsing. 

Among  the  causes  of  this  disorder  are  excessive  stimu- 
lation of  the  emotions,  over-excitement  of  the  sexual  organs, 
overwork  and  mental  exhaustion,  late  retiring  followed 
by  early  rising,  aneemia,  hydrsemia,  and  bad  digestion 
resulting  from  bad  air  and  unhygienic  living.  It  is  rather 
an  obscure  affection  and  difficult  of  diagnosis,  distinguished 
from  inflammatory  affections  of  the  cord  hj  the  non-ap- 
pearance of  permanent  anaesthesias  and- paralyses,  and  by 
the  absence  of  the  sensation  of  a  cord -like  constriction 
around  the  abdomen,  and  of  severe  spasms  and  contrac- 
tures. There  is  no  elevation  of  temperature  and  no  marked 
muscular  atrophy  in  this  disorder. 

The  treatment  consists  in  improving  the  quality  of  the 
blood,  giving  easily  digested  nutritious  food  after  correct- 
ing digestive  disorders,  and  the  administration  of  strych- 
nine, quinine,  and  iron  in  moderate  doses. 

The  hygienic  surroundings  should  be  looked  to.  Coun- 
try life  with  horseback  or  bicycle  riding,  should  be  recom- 
mended, but  the  exercise  should  not  be  carried  to  the  point 
of  severe  fatigue.  Hydrotherapeutic  measures  may  be 
employed  with  advantage.  Hot  applications  to  the  dor- 
sal spine  are  often  of  value.  The  foregoing  methods  of 
treatment  should   be   used  with   caution,   and  measures. 


SPIIfAL    REFLEX    NEUROSES.  41 

particularly   of   a    severe    nature,  should   be   tentatively 
employed. 

In  the  ansemic  type  of  spinal  irritation,  weakness  and 
exhaustion  are  the  predominant  symptoms ;  pain  is  also 
present  but  is  not  severe  or  persistent.  The  patients  tire 
very  readily :  after  slight  physical  exertion,  a  short  walk, 
ascending  a  single  flight  of  stairs,  standing  for  a  short 
length  of  time,  they  are  compelled  to  retire  to  bed.  Sleep 
is  unnatural  and  disturbed,  and  they  generally  feel  as  ex- 
hausted and  prostrate  on  rising  as  they  did  on  retiring. 
They  are  frequently  hypochondriacal  and  suffer  from  a 
dread  of  fatal  maladies  such  as  paralysis,  heart  disease, 
consumption,  etc.,  often  having  their  hearts  and  lungs 
examined  by  physicians.  Digestion  in  these  patients  is 
generally  weak,  and  they  usually  suffer  with  cold  hands 
and  feet.  This  neurasthenic  condition  may  last  for  many 
years  and  may  sometimes  even  degenerate  into  organic 
disease  of  the  spinal  cord.  Among  the  more  common 
causes  of  this  disorder  is  excessive  irritation  of  the  sexual 
organs,  excessive  insomnia,  great  mental  exertion,  and  bad 
dietetic  habits. 

The  treatment  should  consist  of  forced  feeding,  rest, 
change  of  scene,  abstention  from  sexual  excitement  and 
mental  exertion.  The  food  should  be  nitrogenous  and  easy 
of  digestion.  A  stimulant  of  porter,  ale,  beer,  or  light 
wine  should  be  taken  with  the  food,  and  tonic  drugs  such 
as  nux  vomica,  cinchona,  and  iron  employed.  Sea-bathing 
in  great  moderation  is  often  of  much  benefit,  as  is  the  ap- 
plication of  static  electricity.  The  patients  with  these  neu- 
roses are  usually  the  daughters  of  wealthy  neurotics  who 
have  exhausted  their  vitality  in  the  struggle  for  money. 


CHAPTER  IV. 

CARDIAC  REFLEX  NEUROSES. 

Stimuli  arising  from  diseased  states  of  the  gastro-intes- 
tinal  or  uterine  organs  are  fully  as  powerful  as  the  emo- 
tions in  causing  cardiac  disturbance,  and  for  this  reason 
the  cardiac  neuroses  are  frequently  dependent  not  only 
upon  diseased  conditions  in  the  cranial,  but  also  in  the 
thoracic  and  abdominal,  cavities. 

Among  the  cardiac  neuroses  are:  (1)  palpitations;  (2) 
tachycardia ;  (3)  bradycardia ;  (4)  intermittent  and  irregu- 
lar heart  action ;  and  (5)  angina  pectoris. 

Cardiac  reflex  neuroses  are  quite  common;  they  take 
their  origin  not  only  in  uterine  and  gastro-intestinal  dis- 
turbance, and  are  frequently  dependent  upon  an  excitation 
of  the  emotions,  but  may  result  from  severe  cutaneous  im- 
pressions. The  intimate  connection  of  the  sympathetic 
nerves  gives  ample  opportunity  for  the  development  of 
functional  disorders  of  the  heart.  The  most  severe  and 
important  of  these  neuroses  is  pseudo-angina  pectoris,  not 
only  on  account  of  its  frequency  but  from  its  close  simu- 
lation of  the  true  disease.  In  the  functional  form  of  the 
disorder  there  is  no  organic  lesion  present;  the  pain  is  of 
the  same  type  and  follows  the  same  direction  as  in  the  true 
form  of  the  disease,  running  down  the  left  shoulder 
through  the  arm  and  hand.  The  attacks  are  not  constant 
and  there  is  frequent  soreness  over  the  region  of  the  heart. 
In  weak  and  hysterical  women  with  this  affection,  the  least 

exertion  starts  up  an  attack  of  palpitation  with  vertigo  as 

42 


CAEDIAC    REFLEX    NEUROSES.  43 

a  result.  Sometiinas  this  continues  for  quite  a  time,  with 
pain  in  the  region  of  the  heart,  and  breathing  also  gives 
more  or  less  pain.  Numbness  in  the  arm  and  hand  is  very- 
frequent  and  neuralgic  pains  in  the  arm  are  often  present. 
The  palpitations  are  generally  relieved  by  a  few  moderate, 
doses  of  tincture  of  strophanthus.  Women  approaching 
the  menopause  are  more  liable  to  the  disorder  than  at  other 
periods,  although  it  is  common  in  dyspeptic  girls.  In  the 
milder  forms  of  the  disease  the  attacks  may  last  but  a  few 
seconds,  the  patient  experiencing  first  a  sharp  pain  similar 
to  a  "stitch"  in  the  cardiac  region.  Simultaneous  with 
these  there  is  a  sensation  as  if  of  suffocation.  The  patient, 
finds  it  impossible  to  breathe.  This  continues  and  the  paiu 
in  the  heart  becomes  extremely  severe.  The  left  arm 
and  hand  twitch  and  seem  to  straighten  out  and  become 
rigid.  This  entire  process  may  only  occupy  a  few  seconds. 
The  patient  thinks  while  it  lasts  that  death  is  imminent. 
During  the  attack  the  proper  treatment  is  the  hypodermic 
injection  of  either  morphine  with  atropine,  or  ether,  pref- 
erably the  former.  The  use  of  each  depends  upon  the 
pulse — a  strong  pulse  indicating  morphine  while  a  weak 
one  calls  for  ether. 

The  cardiac  neuroses  dependent  upon  pelvic  or  digestive 
disorder  have  not  hitherto  received  in  medical  treatises  the 
amount  of  attention  which  their  importance  and  frequency- 
call  for.  In  the  treatment  of  the  abdominal  or  pelvic  dis- 
order upon  which  they  depend,  not  only  local  but  consti- 
tutional treatment  is  usually  necessary. 

It  is  found  that  in  some  of  these  cases  the  emotions  or 
sudden  mental  excitement  will  bring  on  severe  attacks  of 
flatulence  when  the  patient  has  hitherto  been  quite  free 
from  it.  It  often  seems  to  be  of  a  neurotic  origin,  and 
it  is  a  debated  question  where  the  gas  comes  from.     The 


44  FUNCTIONAL    NERVOUS    DISORDERS. 

flatulence  is  said  to  arise  quite  independently  of  fermen- 
tation. 

Some  patients  have  a  great  deal  more  vitality  than 
others;  two  individuals  may  apparently  have  the  same 
amount  of  strength,  but,  as  it  has  been  aptly  put,  one  has 
much  better  "timber"  than  the  other,  and  consequently 
greater  vital  resistance  to  disease.  The  difference  between 
the  two  manifests  itself  nowhere  more  completely  than  in 
the  heart  muscle,  one  withstanding  all  sorts  of  mental 
strain,  physical  hardships,  and  disease,  without  apparent  ill 
results,  and  the  other  very  readily  collapsing  under  simply 
depressing  influences.  The  pulse,  respiration,  and  general 
aspect  may,  to  our  crude  methods  of  observation,  be  appar- 
ently the  same  in  both  cases,  yet  one  is  on  the  verge  of  col- 
lapse. Many  patients  have  a  presentiment  of  impending- 
dissolution.  This  is  the  result  of  the  failure  of  vital  forces 
manifesting  itself  to  the  individual  by  some  curious  mental 
process.  I  have  seen  a  case  of  this  kind  in  which  the  pre- 
sentiment was  verified,  the  woman  dying  of  concealed 
accidental  hemorrhage.  The  same  feeling  occurs  in  severe 
cases  of  haemoptysis  and  haematemesis. 

Dr.  George  W.  Jacoby,  in  the  New  York  Medical 
Journal  for  April  8th,  1893,  states  that  in  probablj^  more 
than  one-half  of  the  persons  suffering  with  motor  disorder 
of  the  heart  no  anatomical  lesion  is  discoverable ;  he  con- 
siders the  subject  one  of  great  practical  interest  and  divides 
the  motor  neuroses  into  the  intermittent,  irregulai:,  those 
that  are  abnormally  slow  (bradycardia)  and  those  that  are 
abnormally  frequent  (tachycardia) .  In  arhythmical  forms 
of  the  disorder  he  states  that  the  cause  ought  to  be  sought 
in  some  disorder  of  the  digestive  tract,  and  that  it  is  ex- 
plicable by  reflex  through  the  vagus,  and  that  a  general 
neurasthenia  is  often  present. 


CARDIAC  REFLEX  NEUROSES.  45 

Alcohol  and  tobacco  are  well-known  factors  in  the  pro- 
duction of  these  disorders.  In  bradycardia  the  digestive 
tract  is  credited  with  being  the  disturbing  factor ;  in  tachy- 
cardia (which  is  not  at  all  the  same  as  palpitation),  the 
heart  beat  is  perfectly  regular  but  very  rapid.  It  generally 
takes  place  in  neurasthenic  patients,  as  shown  by  the 
marked  disorder  of  the  urinary  discharge,  this  sometimes 
being  very  excessive  and  at  other  times  exceedingly 
scanty.  Mental  influences  and  digestive  disturbances  are 
placed  as  prominent  factors  in  its  production.  In  his  valu- 
able article  Dr.  Jacoby  states  that  he  is  quite  convinced 
that  the  neuroses  are  often  the  precursors  of  organic  dis- 
ease. He  says :  "  So  long  as  the  equilibrium  of  the  ner- 
vous system  can  be  re-established  after  functional  disorder, 
so  long  as  repair  out-balances  waste,  so  long  can  we  speak 
of  functional  disorder;  as  soon,  however,  as  waste  is  in  ex- 
cess of  repair,  so  soon  do  we  have  lesion,  and  with  it 
organic  disease.  So  in  all  these  cases  of  motor  neuroses  of 
the  heart,  what  to-day  we  may  look  upon  as  a  pure  neurosis 
may  remain  so  for  a  period  of  time  and  then  get  well,  or 
may  develop  into  organic  disease.  Their  prognosis,  there- 
fore, is  not  to  be  estimated  from  the  cardiac  symptoms 
alone."  This  is  my  experience  also  in  the  motor  neuroses 
of  the  heart  and  the  cases  of  pseudo-angina  pectoris  which 
I  have  treated.  We  never  know  when  they  may  show 
themselves  as  symptoms  of  organic  lesions. 

The  cardiac  reflex  neuroses  are  evidences  in  very  many 
cases  of  a  weakened  heart  muscle,  and  in  some  patients, 
especially  those  who  are  far  advanced  in  years,  there 
is  a  possibility  of  their  being  snuffed  out  at  any  time, 
the  post-mortem  showing  probably  nothing  more  than  a 
slight  enlargement  with  some  minor  degenerative  changes 
in  the  heart  muscle,  no  valvular  lesions  being  present. 


46  FuisrcTioisrAL  jsteevous  disorders. 

The  heart  disorder  is  simply  a  part  of  the  general  arte- 
rial change,  which  includes  all  portions  of  the  body  and 
shows  itself  especially  in  the  kidneys. 

Mrs.  B.,  set.  26,  is  a  thin,  ansemic  blonde,  now  con- 
valescing from  her  first  confinement.  On  the  fourth  day 
after  delivery  I  first  saw  this  patient  in  consultation. 
Her  pulse  at  this  time  was  but  38  and  regular;  there  was 
no  sign  of  any  disorder  of  the  valves  or  of  the  heart  muscle. 
Her  appetite  is  fair,  and  the  only  discoverable  troubles  are 
a  slight  gastric  irritation  and  pain  and  tenderness,  not  of  a 
very  marked  character,  in  the  region  of  the  right  ovary. 
She  tells  me  that  before  becoming  pregnant  she  suffered  for 
a  considerable  time  from  leucorrhoea.  On  the  eighth  day 
after  her  delivery  the  pulse  rose  to  66  and  after  slight  exer- 
tion was  72  for  a  short  while,  but  fell  again  to  66. 

Mrs.  B.  K.,  4o  years  of  age,  an  ansemic  blonde,  has  had 
seven  children.  During  every  pregnancy  she  has  had 
frequent  attacks  of  cardiac  palpitation,  has  also  suffered 
with  heartburn  and  a  considerable  amount  of  flatulence. 
Attacks  of  nervousness  and  fear  were  also  present,  and  the 
sight  of  water  or  (in  winter)  of  the  windows  covered  with 
frost,  would  induce  an  attack  of  this  kind.  In  the  middle 
of  her  last  pregnancy  an  attack  of  la  grippe  caused  a  great 
increase  in  the  number  of  these  manifestations.  The 
cardiac  palpitations  at  this  time  persisted  without  inter- 
mission for  four  days  and  nights  (tachycardia).  The 
attacks  of  nervousness  and  fear  come  on  generally  at 
night,  but  sometimes  in  the  afternoon,  with  intense  redness 
of  the  face.  She  is  compelled  to  jump  up  and  move  around, 
as  she  cannot  remain  quiet  while  they  are  present.  When 
the  uterus  is  in  the  unimpregnated  state  she  does  not  suffer 
from  any  of  these  disorders.  This  would  point  to  a  causal 
relationship  between  them,  and  would  tend  to  show  their 
reflex  character. 


CHAPTER  V. 

VASCULAR  NEUROSES. 

The  vascular  neuroses  are  the  vasomotor  or  those  of  the 
peripheral  circulation.  They  may  be  general  or  local,  ex- 
ternal or  internal — external,  as  in  a  morbid  blush,  or  in- 
ternal, as  in  a  globus  hystericus. 

Vasomotor  neuroses  are  exceedingly  complex  phenomena, 
the  causes  and  results  of  which  are  often  difficult  of  eluci- 
dation. In  giving  them  consideration  one  should  remem- 
ber accurately  the  anatomy  and  physiology  of  the  parts 
involved  in  their  production. 

Among  the  more  marked  of  the  general  vascular  neu- 
roses is  the  hysterical  or  nervous  fever  mentioned  below, 
usually  resulting  from  some  uterine  or  digestive  difficulty. 
General  nervous  chills  are  also  a  vasomotor  disorder  de- 
pendent upon  some  local  irritation,  either  cerebral,  ab- 
dominal, or  pelvic.  Febrile  conditions  dependent  on 
uterine  disease  are  very  common  at  the  menopause ;  they 
often  simulate  malarial  fevers,  but  are  not  benefited  by 
quinine.  Treatment  directed  to  the  uterine  trouble  often 
gives  relief.  In  some  cases  they  have  their  origin  in  ab- 
normalities of  the  menstrual  flow. 

Among  the  local  vascular  neuroses  we  find  flushes, 
morbid  blushing,  extreme  redness  of  the  nose  and  malar 
prominences,  burnings  of  the  palms  of  the  hands,  soles  of 

the  feet,  top  of  the  head,  side  of  the  chest,  erythematous 

47 


48  FUNCTIOlSrAL    I^TERVOUS    DISORDERS. 

eruptions,  hemorrhages,  sweats — sometimes  unilateral  or 
confined  to  the  hands  and  feet — coldness  of  the  extremities, 
dryness  of  the  body. 

I  have  seen  a  number  of  cases  of  morbid  flushing  or 
blushing  in  my  practice,  and  a  few  of  them  I  have  con- 
sidered of  sufficient  importance  to  justify  me  in  taking- 
notes  of  them.  In  looking  up  the  subject  in  medical  lit- 
erature I  could  find  but  comparatively  little  bearing  upon 
it.  Dr.  Harry  Campbell,  of  London,  published  a  rather 
extensive  monograph  upon  this  subject  in  August,  1890, 
and  to  it  I  am  indebted  for  much  information. 

The  ganglionic  system  through  the  vasomotor  nerves 
which  control  the  circulation,  and  through  which  it  trans- 
mits irritations  in  the  same  way  as  the  cerebro-spinal 
system,  is  the  important  factor  in  these  neuroses.  Pallor 
and  flushings  show  the  contraction  or  dilatation  of  the 
vessels  through  this  influence.  That  the  mind  is  a  great 
factor  in  many  of  these  states,  or  that  they  are  really  psy- 
choses, is  shown  by  the  condition  of  excessive  or  morbid 
blushing. 

Sometimes  the  irritation  reflected  is  general,  as  in  con- 
ditions of  neurotic  fever  or  when  nervous  chills  occur.  It 
is  said  that  in  some  cases  of  neurotic  fever  the  temperature 
has  even  risen  to  over  110°  F.  Mental  and  nervous  ex- 
citement will  frequently  run  the  temperature  up  to  104°, 
and  this  temperature  will  subside  quickly  without  any 
treatment  other  than  the  removal  of  the  original  cause  of 
excitement.  Besides  being  reflected  generally,  it  is  some- 
times reflected  locally  or  partially,  as  in  cases  of  palsy  of 
the  extremities  or  of  the  face ;  or  sometimes  the  disturb- 
ance is  more  marked,  as  is  seen  in  cases  of  flushings  of  the 
abdomen. 

Morbid  flushing  at  the  menopause  is  very  frequent  as  a 


VASCULAK    REFLEX    JSTEUEOSES.  49 

result  of  genital  disease,  but  in  very  many  cases  I  am  con- 
vinced chronic  gastro-intestinal  catarrh  is  a  still  more  im- 
portant factor  in  lowering  the  tone  of  the  nervous  system. 
In  these  cases  the  gastro-intestinal  canal  needs  treatment 
more  often  than  the  uterus.  In  cases  of  morbid  flushing 
salivation  is  frequently  present.  This  is,  of  course,  a 
glandular  neurosis,  and  it  shows  the  interdependence 
and  identity  of  the  different  forms.  It  must  not  be  con- 
founded with  salivation  from  the  too  free  administration 
of  mercurials.  The  latter  may  be  due  to  the  teeth  contain- 
ing many  fillings  of  cheap  mercurial  amalgam  instead  of 
gold  or  silver.  Dentists  claim  that  this  is  a  not  uncom- 
mon cause  of  mercurial  salivation,  and  it  should  always  be 
borne  in  mind  when  this  symptom  is  observed.  A  flushed 
and  congested  face  with  a  red  and  swollen  nose  is  a  frequent 
gastro-intestinal  vascular  neurosis  or  dermatosis.  The  so- 
called  "  chronic  erysipelas  "  of  the  face  is  a  vascular  der- 
matosis and  comes  under  the  head  of  dermal  neuroses. 
Excessive  perspirations  are  glandular  neuroses,  but  they 
are  of  vasomotor  origin.  It  is  very  difficult  to  separate 
and  classify  these  neuroses,  as  they  are  so  commonly  found 
associated  in  the  same  patient,  and  they  are  also  so  in- 
timately interconnected. 

The  red  nose  and  flushed  cheeks  due  to  reflex  vasomotor 
disorder  are  a  source  of  great  mortification  and  mental  dis- 
tress to  those  so  affected.  It  is  a  most  disagreeable  afflic- 
tion, especially  to  women.  It  has  been  generally  consid- 
ered by  the  ignorant  as  a  sign  of  alcoholic  indulgence : 
more  often  it  is  due  to  gluttony  and  gastro-intestinal  dis- 
ease from  overfeeding  and  high  living.  Particularly  in 
small  provincial  towns  many  persons  have  been  condemned 
as  secret  drinkers  when  they  were  simply  suffering  from 
a  gastro-intestinal  catarrh,  secondary  possibly  to  a  post- 


50  FUifCTIOXAL   NERVOrS    DISORDERS. 

nasal  catarrh,  which  was  unfortunately  manifested  in  a 
disordered  state  of  the  vasomotor  nerves  of  the  face.  Bad 
cooking  and  general  unhj^gienic  living  are  the  usual  causes 
of  this  condition  in  women.  As  an  instance  of  the  way 
the  ignorant  look  at  it,  I  may  quote  a  remark  in  this  con- 
nection which  I  overheard  a  rough  fellow  make :  "  If  they 
don't  drink  they  should  take  in  their  sign."  That  the 
ignorance  is  not  all  confined  to  the  poorer  classes  is  shown 
by  the  dietaries  of  those  in  higher  life.  Extreme  cold- 
ness of  the  extremities  is  a  very  common  vascular  neu- 
rosis due  to  abdominal  or  pelvic  disease,  and  indigestion 
is  fully  as  frequent  a  factor  in  its  causation  as  uterine 
congestions. 

There  are  also  patients  who  suffer  from  extreme  pallor 
of  the  face  whenever  excitement  causes  the  heart  to  beat 
furiously.  Some  of  these  local  vascular  neuroses  become 
chronic  and  exist  as  dermatoses,  like  acne  rosacea  and 
chronic  urticaria.  Upon  the  disappearance  of  the  local 
disease  these  reflex  disorders  cease  to  exist.  The  flushed 
appearance  is,  in  many  of  these  cases,  due  to  a  vasomotor 
paralysis.  Some  of  these  patients  will  frequently  have 
the  upper  portion  of  the  body  in  a  constant  flush,  while  the 
feet  will  be  cold  as  ice.  Insomnia  is  here  often  present, 
sometimes  of  such  a  severe  type  as  to  lead  to  mild  forms 
of  mental  aberration.  Vasomotor  paralysis,  causing  burn- 
ing sensations  at  the  vertex  and  occiput,  is  a  very  common 
symptom  of  uterine  or  ovarian  disease.  Coldness  of  the 
extremities  is  not  only  present  in  disorders  of  the  uterus 
and  anaemic  conditions,  but  is  a  common  symptom  of  other 
abdominal  difficulties,  such  as  indigestion  and  "bilious- 
ness." "Very  many  patients  with  indigestion  have  numb- 
ness and  coldness  of  the  left  side  of  the  body,  which  is  often 
very  marked,  the  heel  and  the  tips  of  the  toes  and  fingers 


VASCULAR   KEFLEX    XEUROSES.  51 

on  the  left  side  being  sometimes  excessively  cold.  Even 
the  novelists  note  the  vasomotor  changes  dependent  upon 
mental  disturbances  when  they  speak  of  a  heroine's  face 
blanching  and  of  her  "  shivering  and  becoming  cold  with 
nervous  excitement." 

In  hemicrania  and  similar  vasomotor  neuroses  the  arteries 
may  undergo  spasmodic  constriction,  thus  shutting  off  the 
blood  supply  and  rendering  the  parts  pale  and  anaemic;  or 
there  may  be  dilatation  of  the  vessels  with  hypersemia  of 
the  part.  Sometimes  these  conditions  alternate :  there  is 
constriction  followed  by  dilatation,  and  a  consequent 
blanching  followed  by  a  suffusion  of  the  part  affected. 
These  cold  sensations  and  hot  flushes  of  the  skin  are  most 
commonly  seen  at  the  menopause  when  uterine  or  digestive 
disease  is  present,  but  may  occur  at  any  time.  Either  of 
these  two  conditions  continuing  for  a  considerable  space  of 
time  results  in  marked  nutritive  disturbance  of  the  parts 
involved.  In  the  anaemic  type  the  parts  are  pale  and  an- 
esthesia is  present.  In  the  hyperaemic  type  there  is  warmth 
and  redness  of  the  part  with  some  slight  hyperesthesia; 
the  glands  involved  are  stimulated  and  there  is  increased 
secretion.  Profuse  perspiration  may,  however,  take  place 
in  this  disorder  without  any  other  symptoms  being  appar- 
ent to  the  observer.  Irritations  of  the  plexuses  and  fila- 
ments of  the  sympathetic  and  cerebro-spinal  systems  from 
disease  in  the  abdominal  or  pelvic  cavities  start  up  many 
vasomotor  disturbances  in  distant  parts  of  the  body.  The 
numbness  with  tingling  present  in  the  left  arm  in  attacks 
of  angina  pectoris  is  a  good  example  of  a  reflex  vasomotor 
neurosis.  Vasomotor  neuroses  of  this  spasmodic  variety 
may  also  depend  upon  ■  ovarian  irritation.  If  the  causa- 
tive lesion  is  central,  as  in  a  case  of  endometritis,  we  may 
find  both  the  lower  extremities  affected  by  a  change  in  the 


52  FUXCTIOXAL   XEEYOUS    DISORDEES. 

vascular  supply  and  lu  the  sensation  of  the  parts,  frequently 
causing  reflex  paraplegia. 

Mrs.  T.,  get.  76,  has  had  attacks  of  angina  pectoris. 
Her  left  arm  is  considerably  weaker  than  the  right  and 
at  times  is  painful,  particularly  in  the  centre  of  the  palm 
and  the  front  of  the  elbow  joint,  with  numbness  and 
tingling  of  the  fingers;  the  arm  is  cold,  but  its  nutri- 
tion does  not  seem  to  be  impaired.  Only  by  the  most  care- 
ful examination  can  the  pulsation  be  detected  in  the  radial 
artery  at  the  left  wrist,  and  it  is  impossible  to  count  it ; 
the  pulse  in  the  right  radial  is  very  strong.  When  she 
was  very  much  younger,  she  says,  her  physician  never 
noted  an'y  special  difference  between  the  pulsations  of  the 
two  radials,  or,  if  he  did,  which  is  more  likely,  he  never 
spoke  of  it.  She  had  suffered  since  girlhood  with  cardiac 
weakness.  In  some  patients  this  condition  of  spasmodic 
contraction  of  the  blood-vessels  is  temporary  when  depend- 
ent upon  abdominal  or  pelvic  disease,  and  disappears 
readily  on  removal  of  the  causative  lesion,  the  pulse  in 
both  arms,  and  probably  in  both  feet,  in  many  cases  be- 
coming equal  in  strength. 

Morbid  flushing,  as  a  vasomotor  disturbance,  is  due  often- 
times to  want  of  tone  in  the  surface  vessels,  which  thus 
causes  either  great  pallor  or  flushing  of  the  part.  It  is 
this  want  of  tone  also  in  the  deeper  vessels  which  probably 
causes  the  congestive  and  anaemic  types  of  neuralgic  head- 
aches, and  there  are,  I  believe,  undoubtedly  extreme  states 
of  pallor  or  flushing  of  the  cerebral  tissue,  the  same  as  we 
frequently  see  on  the  surface  of  the  skin.  Areas  of  pallor 
in  the  brain  may  give  rise  to  symptoms  like  anaemic  roar- 
ing, snappings,  whistlings,  etc.  These  patients  frequently 
have  anaemia  of  all  the  extremities,  suffering  intensely 
from  cold  hands  and  feet.  There  can  be  no  doubt  that  the 
intracranial  blood  pressure  is  to  a  degree  under  the  control 


YASCULAK    KEFLEX    IS^EUEOSES.  53 

of  the  sympathetic  nervous  system,  the  same  as  the  blood 
supply  in  other  parts  of  the  body.  In  considering  the 
sympathetic  system  and  its  connections  we  need  simply 
outline  the  circulatory  apparatus,  as  in  this  department  it 
manifests  its  greatest  changes.  Excessive  emotion,  shown 
by  morbid  blushing,  is  due  in  many  cases  to  a  weakened 
condition  of  the  sympathetic  nerves  and  to  ansemia  result- 
ing from  fatigue,  insufficient  sleep,  and  exhaustion. 
Morbid  blushing,  although  not,  strictly  speaking,  a  serious 
disorder,  is,  to  say  the  least,  extremely  disagreeable  to 
the  victim.  It  is  simply  the  manifestation  of  a  weakness 
in  the  nervous  system.  It  is  not  the  symptom  of  blushing 
which  needs  treatment,  but  the  general  condition  which  is 
at  the  basis  of  the  disorder.  Probably  the  most  prominent 
exciting  cause  is  self-consciousness,  either  by  introspection 
or  by  the  attention  being  drawn  to  the  external  portions  of 
the  body  while  under  examination  by  others. 

If  a  modest  individual  of  extremely  nervous  tem- 
perament is  in  company  with  a  number  of  persons,  and 
imagines  that  the  people  around  her  are  regarding  her 
critically  and  are  entertaining  rather  a  disparaging  opinion 
of  her,  she  is  very  liable  to  manifest  her  abnormal  self- 
consciousness  by  blushing,  or  even  by  becoming  embar- 
rassed in  her  conversation,  and  stammering.  Shy  and 
nervous  persons  blush  readily  when  attention  or  remarks 
are  directed  to  their  personal  appearance.  Women  are 
said  to  suffer  more  frequently  than  men  from  this  disorder; 
but  there  are  many  men  whose  nervous  system  is  disor- 
dered, either  congenitally  or  by  exhausting  mental  or 
physical  work,  who  are  much  given  to  blushing  and  other 
manifestations  of  nervous  weakness.  The  young  blush 
much  more  pronouncedly  than  those  who  are  older,  not 
only  on  account  of  the  texture  of  the  skin  being  more  deli- 


54  FUNCTIOlSrAL   NEKVOUS    DISORDERS. 

cate  and  healthful,  but  from  inexperience  and  on  account 
of  their  condition  of  h3'persensitiveness  not  having  as  yet 
been  blunted  by  continued  contact  with  the  world.  Blush- 
ing is  generally  confined  to  the  face,  on  account  of  its  ex- 
treme vascularity,  and  therefore,  having  a  greater  supply  of 
vasomotor  nerves,  emotional  disturbances  manifest  them- 
selves more  prominently  in  that  part,  the  face  being  the 
portion  of  the  bodj^'  most  exposed  to  view  and  upon  which 
most  attention  is  concentrated  in  looking  for  recognition, 
or  in  studying  character  or  discerning  beautj^  or  homeli- 
ness. The  self-attention  thus  given  the  face  makes  it 
abnormally  sensitive  and  the  vessels  extremely  prone  to 
dilate,  with  blushing  as  a  result. 

It  is  said,  among  nations  where  other  parts  of  the  body 
are  exposed  to  view,  that  blushing  is  by  no  means  confined 
to  the  face,  but  is  much  more  widely  diffused. 

Many  people  blush  more  readily  before  strangers  than 
before  acquaintances,  though  sometimes  the  opposite  is  the 
case.  In  some  individuals  the  blushing  takes  place  at 
regular  hours,  and  with  many  it  is  so  severe  that  it  actually 
prevents  them  from  going  into  society.  Blushing  rarely, 
if  ever,  occurs  in  solitude  or  in  darkness ;  it  occurs  only 
when  observation  is  directed  toward  the  personal  appear- 
ance, and  then  results  from  embarrassment  and  self -con- 
sciousness. Anything  which  lowers  the  tone  of  the  ner- 
vous system  tends  to  the  development  of  functional  nervous 
disorders,  of  which  excessive  self-consciousness  is  a  type. 
Many  cultivated  and  scientific  men  are  prone  to  blush  in- 
ordinately from  humility  and  diffidence,  having  a  low 
opinion  of  their  own  ability,  while  the  ignorant  egotist  is 
never  known  to  blush.  That  colored  people  blush  has  been 
proven  by  scars  on  the  face  changing  color  under  condi- 
tions which  would  induce  blushing  in  those  who  are  white. 


VASCULAR    REFLEX    XEUROSES.  55 

Blondes  exhibit  a  tendency  to  blushing,  when  the  skin  is 
healthy,  much  more  vividly  than  do  brunettes  with  sallow 
skins,  although  it  is  quite  probable  that  dark -haired  ladies 
blush  with  fully  as  great  frequency  as  those  who  are  light. 
It  is  more  common  in  those  of  delicate  nervous  organiza- 
tions, while  those  of  coarse  natures  are  very  little  affected 
by  it. 

In  attacks  of  excessive  self -attention,  where  there  is  a. 
difficulty  in  concentrating  the  thoughts,  the  one  idea  be- 
comes unduly  prominent  and  morbid  blushing  results. 
Some  people  blush  on  the  slightest  occasion.  A  case  is 
noted  of  a  telephone  clerk  who  blushes  even  when  convers- 
ing through  the  telephone.  Some  men  cannot  go  into  shops 
where  there  are  women  without  blushing  intenseh'.  Many 
clerks  are  victims  of  blushing,  and,  as  a  result,  suffer  much 
mental  distress  while  serving  customers.  Teachers  blush 
before  their  pupils,  and  men  before  their  wives.  Lovers 
blush  frequently  and  painfully  in  the  presence  of  their 
future  partners.  Lawyers  are  about  the  only  class  to  whom 
this  annoying  affection  is  unknown.  A  grizzled  old  sea- 
captain,  who  passed  many  years  in  command  of  passenger 
ships  crossing  the  Atlantic,  invariably  became  much  em- 
barrassed and  blushed  hotly  when  addressed  by  young  and 
handsome  lady  passengers.  Blushing  is  much  more  fre- 
quent in  old  men  than  in  old  women. 

Predisposition  to  blushing,  like  other  peculiarities  in 
individuals,  is  frequently  inherited.  Darwin  calls  atten- 
tion to  a  case  of  inherited  blushing  which  came  under  the 
observation  of  Sir  James  Paget.  While  conversing  with 
a  young  girl  "  a  big  splash  appeared,  first  on  one  cheek, 
and  then  other  splashes  variously  scattered  over  her  face 
and  neck.  He  subsequently  asked  the  mother  whether  her 
daughter  always  blushed  in  this  peculiar  way,  and  was 


56  FUNCTIONAL    NERVOUS    DISOEDERS. 

answered,  'Yes;  she  takes  after  me.'  Sir  James  Paget 
then  perceived  that  by  asking  this  question  he  had  caused 
the  mother  to  blush,  and  she  exhibited  the  same  peculiarity 
as  her  daughter." 

Many  of  these  inordinate  blushers  are  timid  and  melan- 
cholic, sometimes  to  a  degree  bordering  upon  a  mild  form 
of  mental  aberration.  They  seek  solitude  and  are  exces- 
sively sensitive  about  people  they  meet,  who  they  may 
fancy  are  criticising  their  personal  appearance.  For  this 
reason  they  are  so  shy  that  they  dislike  meeting  friends  or 
strangers  in  the  street.  Many  of  the  victims  of  this  dis- 
order, if  relating  an  incident  or  anecdote,  will  often  lose 
the  thread  of  the  story  by  their  concern  as  to  what  their 
auditors  may  be  thinking  of  them. 

The  best  cure  for  this  condition  of  excessive  self-con- 
sciousness is  a  constant  and  free  intermingling  with  others 
in  the  work  of  life.  Solitude  is  a  great  factor  in  the  pro- 
duction of  self -consciousness.  Poverty  and  worriment  are 
also  elements  in  the  causation  of  excessive  shyness. 

The  preventive  treatment  of  this  condition  should  be 
begun  in  childhood,  by  sending  the  children  to  large  public 
schools  where  they  will  be  allowed  a  considerable  amount 
of  freedom  from  restraint  and  come  in  contact  with  a 
coarser  and  rougher  element.  This  will  tend  to  make  them 
bolder  and  more  self-reliant.  Children  who  seem  to  be 
afflicted  with  shyness  and  inherit  a  morbidly  sensitive 
nervous  disposition,  should  at  a  very  early  age  be  instructed 
in  elocution  and  encouraged,  or  in  fact  compelled,  to  fre- 
quently give  recitations  before  their  classmates.  It  is  also 
well  to  have  them  taught  music  and  singing,  the  exhi- 
bition of  which  accomplishments  before  friends  or  class- 
mates will  materially  tend  to  remove  the  predisposition  to 
shyness  when  present.     It  is  said  that  many  coquettes  have 


VASCULAR    KEFLEX    NEUROSES.  57 

the  power  of  voluntary  blushing.  This  is  likely  to  be  true 
in  some  instances,  as  the  smaller  blood-vessels  of  the  face 
may  probably  be  influenced  through  the  nervous  system  to 
a  certain  extent.  Blushing  often  depends  on  certain  emo- 
tional influences.  When  these  influences  are  but  slight 
the  blushing  maj  be  extremely  evanescent;  when  the 
emotional  changes  are  very  marked  the  blushing  may  be 
very  intense.  Blushing  is  the  external  manifestation  of 
the  internal  emotional  perturbation,  and  its  extent  is  gen- 
erally in  proportion  thereto.  Some  women,  instead  of 
blushing  when  suffering  these  distressing  emotional  dis- 
turbances, become  absolutely  pale.  The  blush  may  be 
preceded  by  very  little  disturbance,  or  it  may  be  ush- 
ered in  by  a  warm  glow  over  the  whole  body.  In  severe 
cases  the  mental  confusion  is  very  marked,  the  heart  throbs 
violently,  there  is  a  sensation  of  suffocation,  and  the  breath 
becomes  short.  There  is  a  peculiar  sensation  at  the  epi- 
gastrium, often  followed  by  the  condition  of  globus  hys- 
tericus or  constriction  of  the  throat. 

Palpitation  of  the  heart  is  a  very  common  condition 
immediately  preceding  the  act  of  blushing.  Many  blush- 
ers experience  a  feeling  of  dread  as  part  of  the  emotional 
state.  The  dread,  breathlessness,  speechlessness,  and  glo- 
bus hystericus  are  all  depressing  emotions,  and  are  often 
accompaniments,  in  a  greater  or  less  degree,  of  the  actual 
blush. 

When  the  blushing  is  of  a  severe  type  there  is  always 
mental  confusion  present.  In  a  large  number  of  cases  the 
individual  completely  loses  the  power  of  thought  for  the 
time  being.  The  mind  is  completely  paralyzed,  and,  in 
popular  language,  she  is  "covered  with  confusion,"  or,  in 
slang  parlance,  "rattled."  There  is  an  instinctive  desire 
for  self -concealment.     The  blusher  either  averts  the  head 


58  FUNCTIOXAL   K"ERVOUS    DISORDERS. 

or  looks  downward.  The  expression,  "  I  wished  I  could 
have  sunk  through  the  floor,"  which  we  have  heard  used, 
aptly  expresses  the  mental  condition  of  the  patient  at  this 
time.  The  overworked  cultured  classes  have,  as  a  rule, 
more  self -consciousness  than  the  uneducated,  but  they  have 
more  power  to  restrain  its  manifestations.  They  very 
rarely  meet  your  gaze  directly,  and  while  conversing 
habitually  look  at  some  adjacent  object,  merely  bestowing 
occasional  side  glances  on  the  person  with  whom  they  are 
conversing.  It  is  almost  impossible  to  compel  any  of  the 
lower  animals  to  look  one  in  the  face  and  eyes  even  for  a 
very  short  space  of  time.  Especially  is  this  the  case  with 
the  dog,  whose  head  you  cannot  possibly  hold  still  for  a 
few  seconds  while  looking  into  his  eyes. 

In  some  cases  of  very  violent  blushing  the  face  becomes 
bathed  in  perspiration.  In  some  women  it  is  so  severe 
that  it  is  followed  by  a  well-marked  rash  which  not  only 
covers  the  face,  chest,  and  neck,  but  may  extend  to  the 
hands.  The  blush  is  often  followed  by  pallor  of  the  face; 
this  is  due  to  constriction  of  the  blood-vessels — a  reaction 
following  their  dilatation.  Morbid  blushing  occurs  most 
frequently  in  women  exhausted  by  anxiety,  the  eating  of 
improperly  cooked  foods,  bad  air,  and  overwork.  The 
blood  of  these  patients  is  usually  anaemic.  When  a  person 
has  once  suffered  from  this  disorder  he  is  liable  to  have 
subsequent  attacks,  as  the  nervous  system  is  highly  im- 
pressionable, and  the  condition  once  well  developed  is 
apt  to  be  perpetuated  by  slight  influences,  such  as  dis- 
ordered digestion. 

Irritations  arising  in  the  digestive  organs  are  probably 
the  chief  causes  of  the  nervous  depression  which  accom- 
panies these  conditions.  The  impure  blood  resulting  from 
the  bad  digestion  produces  most  deleterious  influences  on 


VASCULAR    KEFLEX    N^EUROSES.  59 

the  nervous  system,  thus  starting  up  a  great  variety  of 
functional  disturbances,  of  which  morbid  blushing  is  a 
good  type.  Many  of  these  tendencies  to  weakness  of  the 
digestive  and  nervous  system  are  inherited.  An  impor- 
tant factor,  therefore,  in  the  treatment  of  these  conditions 
is  the  enrichment  and  purification  of  the  blood  by  dietetic 
and  hygienic  means.  As  already  stated,  education  is  a 
great  factor  in  the  treatment  of  hereditary  nervous  weak- 
nesses, and  this  educational  treatment  should  be  begun  at 
a  very  early  age,  when  the  first  demonstrations  of  excessive 
shyness,  which  is  part  of  the  nervous  weakness,  are  noticed. 
Otherwise  it  is  liable  to  increase  in  severity  until  it  be- 
comes an  actual  disease. 

Skilful  care  and  treatment  will  do  much  toward  remov- 
ing this  condition  of  weakness.  Habits  of  solitude  and 
self -communing  should  be  discouraged  and  the  child  should 
be  forced  to  mingle  freely  with  other  children,  which  has  a 
very  wholesome  influence  and  tends  greatly  to  the  modifica- 
tion of  any  peculiarities  of  disposition.  In  the  adult  the 
treatment  is  more  difficult.  Everything  which  contributes 
to  elevate  the  tone  of  the  nervous  system  should  be  adopted. 
Nothing  is  more  important  in  these  cases  than  the  im- 
provement of  the  general  nutrition.  These  neurotics, 
without  exception,  suffer  from  anaemia.  Therefore  the  diet 
and  regimen  require  special  supervision.  Rest,  mental 
and  physical,  with  proper  hygienic  surroundings  and 
forced  scientific  feeding,  will  probably  cure  the  majority 
of  cases.  In  some  of  the  severer  types  massage,  tonic 
baths,  and  electricity  are  indicated.  Many  of  these  cases 
begin  with  dyspepsia,  resulting  often  from  post-nasal 
catarrh.  The  social  instincts  should  be  cultivated  and 
every  possible  effort  made  to  enjoy  life.  In  this  state 
the  nervous  centres  are  exhausted  and  must  be  built  up 


60  FUNCTIONAL   KERVOUS    DISORDERS, 

again  by  the  enriched  blood.  Change  of  climate  to  a 
higher  altitude  is  often  useful  in  these  cases  as  a  stimulant 
to  digestion  and  nutrition.  It  is  in  this  way  that  advan- 
tage is  derived  from  a  trip  to  the  Adirondack  region  or  the 
Rangeley  Lakes  in  Maine.  Out-of-door  exercise,  as  in  the 
treatment  of  all  functional  nervous  disorders,  is  of  the 
greatest  utility.  It'hasamost  favorable  influence  on  the 
general  health.  Wind  and  sun,  having  a  tanning  influ- 
ence on  the  skin,  which  will  render  the  blushing  less  re- 
markable, should  be  courted  as  much  as  possible  when 
taking  outdoor  exercise.  During  attacks  of  blushing  relief 
is  often  obtained  by  lying  down;  they  then  gradually  dis- 
appear under  the  influence  of  rest.  An  irrational  method 
of  living,  by  which  there  is  no  regularity  in  respect  of 
food,  exercise,  and  rest,  is  the  cause  of  most  of  the  weak- 
ness of  the  nervous  system  in  these  individuals.  This  is 
more  particularly  true  among  the  poorer  classes.  The 
women,  looking  after  the  wants  of  the  household,  see  that 
the  other  members  of  the  family  get  food,  but  neglect  to 
supply  themselves  in  a  proper  manner ;  they  thus  soon  be- 
come victims  of  digestive  disorders  and  drift  into  chronic 
invalidism.  Fried  meats,  pastry  and  pickles,  strong  tea, 
coffee,  and  wines,  are  all  agents  in  retarding  the  digestion 
and  impoverishing  the  blood.  Morbid  blushing  is  often 
caused  by  bad  digestion.  The  irritative  action  of  wines  or 
other  alcoholic  drinks  on  the  mucous  membrane  of  the 
stomach  reflexly  causes  flushing  of  the  face. 

Cold  bathing  is  preventive  and  also  exercises  a  curative 
influence  on  this  state;  but  as  in  many  cases  the  cold  bath 
is  injurious  and  cannot  be  tolerated,  the  patient  should  be 
gradually  trained  to  resist  its  depressing  influence.  The 
bath  should  be  first  given  tepid  and  the  temperature  grad- 
ually lowered  in  each  succeeding  bath.     The  immersion 


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VASCULAR    REFLEX    NEUROSES.  61 

should  be  of  very  short  duration,  and  should  be  imme- 
diately followed  by  vigorous  friction  with  a  coarse  towel 
or  a  flesh-brush  or  bath-glove,  and  finally  the  application 
of  the  warm  bare  hand  until  the  entire  surface  of  the 
body  glows.  Hot  baths  are  often  very  beneficial  to  ner- 
vous patients  and  are  best  taken  before  retiring. 

Electricity  is  of  considerable  advantage  in  these  cases 
of  nervousness ;  mild  galvanism  should  be  applied  daily  for 
a  short  time  only. 

If  the  face  is  heated  and  reddened  by  sitting  in  close 
proximity  to  the  fire  or  by  bathing  it  in  very  hot  water,  it 
will  give  immunity  from  blushing  for  a  very  considerable 

time. 

Many  drugs  are  of  great  advantage  in  this  disorder, 
notably  iron,  quinine,  camphor,  and  turpentine.  Stimu- 
lants are  very  disadvantageous  and  should  be  avoided  as 
much  a  possible. 

Vasomotor  Disorder.  Abdominal  Flushing.— Mts. 
A.  E.  (see  plate),  40  years  of  age;  seven  years  married,  but 
never  pregnant.  She  has  been  ailing  ever  since  her  mar- 
riage. Before  this  she  worked  hard  at  monthly  nursing. 
For  several  years  past  she  has  suffered  from  constant  pain 
in  the  lumbar  region  posteriorly.  Frequently  suffers  from 
severe  pain  and  a  sensation  of  burning  in  the  vertex,  neces- 
sitating the  use  of  local  applications  for  relief.  Feels  con- 
stantly fatigued  and  is  compelled  to  He  down  frequently. 
Has  "  no  ambition  or  appetite. "  For  years  past  she  has  not 
taken  any  breakfast,  with  the  exception  of  three  or  four 
cups  of  strong  coffee.  During  menstruation  nothing  is 
retained  on  the  stomach  except  the  coffee.  Now  menstru- 
ates every  two  weeks,  and  during  these  periods  the  ab- 
domen becomes  swelled  and  assumes  a  dark  or  bluish-red 
color  and  feels  very  hard;  at  the  same  time  the  lower 
extremities  are  "  just  like  death,  cold  and  clammy. "  There 
is  also  severe  abdominal  pain  and  the  face  is  exceptionally 


62  FUXCTIOXAL    iN'ERYOUS    DISORDERS. 

red  and  hot.  She  feels  feverish  and  thirsty,  and  has  "  fever 
sores"  about  the  nose  and  mouth.  There  is  also  inconti- 
nence of  urine,  and  the  urine  is  scanty  by  day  but  excessive 
by  night.  During  menstruation  the  bowels  do  not  move, 
even  after  enemata.  The  tongue  is  coated  with  a  whitish- 
brown  fur.  During  her  menses  she  is  compelled  to  remain 
in  bed,  and  during  her  last  period  was  delirious  and  tore 
her  hair  out  in  handfuls. 

Vasomotor  paresis  of  the  lower  extremities  sometimes 
takes  place  in  the  nervous  and  hysterical,  in  which  the 
legs  become  extremely  hard  and  engorged  almost  to  burst- 
ing. This  also  occurs  at  times  in  the  hands  or  face.  In 
speaking  of  a  case  of  this  type  where  the  abdomen  was  the 
seat  of  the  disorder.  Dr.  Weir  Mitchell  says :  "  The  last 
case  of  hysterical  vasomotor  manifestations  which  I  shall 
quote  was  so  amazing  that  if  I  had  not  had  the  good  for- 
tune to  see  it  over  and  over,  and  to  show  it  once  to  my 
friend  Dr.  William  V.  Keating,  I  might  reasonably  have 
hesitated  to  tax  the  credulity  of  my  hearers. 

"  Some  twenty  years  ago  I  attended  a  3"0ung  married 
woman  whose  life  was  embittered  by  losses  of  property  and 
by  the  ill  treatment  of  her  husband,  who  finally  deserted 
her.  For  a  long  period  she  exhibited,  at  times,  hysteric 
disorders  in  the  form  of  spasms,  rigors,  hemipalsies,  and 
at  last,  for  a  month  or  two,  moderate  maniacal  excitement. 
With  favoring  circumstances  she  at  last  got  well,  and  re- 
moving to  the  West  was  lost  sight  of  until  about  ten  years 
ago,  when  I  was  called  to  see  her  at  a  hotel  in  Philadel- 
phia. At  this  time  my  patient  was  35  j^ears  old,  was 
irregular  as  to  her  monthh"  flow,  and  had,  as  I  found,  a 
womb  tilted  forward  but  not  diseased,  and  no  ovarian 
tenderness,  or,  at  least,  no  tenderness  of  belly  which  was 
not  the  same  everywhere.  She  was  rather  pale  and  very 
thin,  and  had  a  relaxed  pendent  abdomen  marked  by  the 
scars  of  four  pregnancies.     I  could  find  no  disease  of  heart, 


VASCULAR  REFLEX  XEUROSES.  63 

lungs,  or  kidney.  She  gave  me  this  brief  history:  After 
some  years  of  ease  and  comfort  she  had  been  led  to  risk 
her  property  in  a  wild  speculation  which  ruined  her,  and 
now  she  was  keeping  a  boarding-house  in  New  York  and 
was  doing  well,  or  likely  to  do  well,  except  for  the  strange 
malady  for  which  she  came  to  consult  me.  After  her  new 
misfortunes  she  had  some  hysterical  troubles,  but  these 
ceased  to  annoj^  her,  and  she  began  to  observe  that  at  or 
about  the  time  of  her  menstrual  flow,  and  afterward  at  any 
time,  she  was  liable  to  have  an  enlargement  of  the  belly, 
which  did  not  seem  to  her  to  be  due  to  wind,  as  with  that 
form  of  swelling  her  previous  experience  had  made  her 
but  too  fully  acquainted.  The  trouble  became  by  degrees 
worse,  and  at  last  was  so  extreme  as  to  cause  certain  un- 
pleasant feelings  and  to  subject  her  to  suspicions  of  being 
pregnant. 

"  The  swelling  was  certainly  caused  at  times  by  emotion. 
It  began  at  an}^  time,  rarely  at  night.  Within  a  few 
hours  the  belly,  in  place  of  being  flaccid  and  pendent,  w^as 
swollen  enormously.  She  looked,  in  fact,  as  a  woman, 
thin  as  she  was,  w^ould  have  looked  at  the  eighth  month  of 
pregnancy.  Other  attacks  were  less  severe,  but  always 
they  lasted  for  some  hours  before  she  could  stand  up,  and 
it  was  usually  a  week  before  she  was  well. 

"When  I  saw  her  an  attack  was  at  its  worst.  The 
woman's  pulse  was  about  165  and  was  a  mere  thread,  at 
times  imperceptible.  Her  face  and  limbs  were  white  and 
cold.  The  abdomen  was  tense  and  red  and  could  be  felt 
to  throb  distinctly,  while  all  over  it  the  vessels,  veins,  and 
arteries  were  visibly  enlarged.  On  listening  over  the 
belly  I  could  hear  a  humming  noise,  a  slight  thrill.  The 
chest  itself  was  not  quite  so  pale  as  the  neck  or  face,  but 
the  breath  was  difficult  and  rapid.  It  was  clear  that, 
owing  to  palsy  of  all  the  abdominal  vessels,  all  the  avail- 
able blood  of  the  body  of  a  too  bloodless  woman  was  for  a 
time  in  this  cavity  and  its  walls.  If  while  in  this  state 
she  sat  up  she  instantly  fainted,  and  it  was  difficult  even 
to  lift  her  head  because  of  the  symptoms  thus  caused.     She 


64  FUlS'CTIOIirAL    NERVOUS    DISORDERS. 

herself  complained  of  the  tension  of  the  belly  and  of  the 
distressing  pulsation  within  it. 

"  The  day  after,  the  abdomen  was  certainly  a  third  less, 
and.  it  was  then  seen  by  Dr.  Keating,  who,  like  myself, 
could  give  no  other  explanation  of  the  condition  seen  than 
the  one  I  have  just  mentioned.  After  a  week  the  belly 
became  nearly  as  flat  as  usual  and  I  then  ceased  to  see  my 
patient.  I  learned  from  her  some  years  later  that  by  slow 
degrees  she  had  become  well  of  this  singular  malady." 

A  former  United  States  Senator  from  Rhode  Island  was 
noted  as  exhibiting  a  peculiar  phase  of  morbid  blushing 
during  his  forensic  efforts :  his  face  seemed  to  be  divided 
into  thirds ;  the  centre  of  the  face  from  forehead  to  chin 
would  become  extremely  red,  while  his  ears  and  the  sides 
of  his  cheeks  would  exhibit  the  opposite  condition  of  ex- 
treme pallor. 

Morbid  Flushing — Vasomotor  Disorder  after  Herai- 
plegia  —  Diabetes  —  Dietetic  Treatment  —  Recovery.  — 
Mrs.  K.  (see  plate,  Fig.  6),  68  years  of  age.  About  twelve 
years  ago  she  had  an  attack  of  hemiplegia  on  the  right  side. 
She  can  see  but  very  little  with  the  right  eye.  Whenever 
she  takes  a  small  quantity  of  tea  it  sends  the  blood  to  one 
side  of  the  face,  accompanied  by  a  tingling  sensation; 
coffee  has  no  such  effect.  This  also  occurs  when  she  is 
excited  and  when  busily  engaged  in  mental  work.  This 
she  has  learned  to  look  upon  as  a  warning  to  desist  from 
excitement  or  mental  strain.  She  is  often  kept  awake  at 
night  from  nervousness  excited  by  the  burning  and  tin- 
gling. The  patient  is  very  stout  and  suffers  from  the  fat 
form  of  diabetes.  Under  dietetic  treatment,  both  liquid 
and  solid,  the  sugar  has  disappeared  from  her  urine  and 
she  is  now  in  fair  health. 

Functional  Vasomotor  Disorder — Unilateral  Flush- 
ing.— M.  F.  (see  plate,  Fig.  4) ,  aged  20,  single.  Seen  Janu- 
ary 1st,  1892.  Strong,  tall  blonde.  Unilateral  flushing 
of  right  side  of  face.     It  came  on  first  three  months  ago. 


M9GimCTiddy.-Pla^e  II 


Fig.l 


H§.2 


'"^.^ 


Fig.  3 


Fig.4- 


W  <^     '®= 


'  ?»..      .r»J 


V^ 


Fi§-5 


Fi§-6 


CASES  OF  MORBID  BLUSHING. 


VASCULAR  EEFLEX  NEUEOSES.  65 

eight  days  befote  menstrual  period,  and  was  coincident 
with  an  attack  of  leucorrhoea.  Has  also  occurred  from 
three  to  eight  days  before  menstrual  period.  Her  face  is 
pale  at  first,  but  gradually  gets  red  until  most  of  right  side 
is  extremely  so,  the  left  side  remaining  pale.  The  redness 
disappears  as  the  menstrual  flow  comes  on. 

Nervous  Unilateral  Flushings  and  Indigestion. — 
Mrs.  A.  Z.  (see  plate,  Fig.  5),  27  years  of  age,  has  had 
two  children.  She  is  extremely  nervous,  especially  after 
a  hearty  meal.  When  digestion  is  slow,  as  it  usually  is,  it 
is  generally  accompanied  by  palpitatioi;i  of  the  heart.  She 
had  malaria  when  in  the  country  five  years  ago.  She  was 
well  up  to  that  time.  Her  indigestion  is  accompanied  by 
flatulence  and  eructations,  but  these  are  not  very  severe. 
Two  weeks  ago  she  was  seized  with  a  very  severe  head- 
ache. This  was  similar  to  those  she  had  had  at  every 
menstrual  period  for  the  past  five  years.  Occasionally  a 
period  is  not  accompanied  by  this  headache,  but  if  so  the 
headache  is  much  worse  at  the  next  period.  They  are 
migrainous  in  character  and  are  generally  located  in  the 
right  temple.  At  times  she  suffers  from  severe  gastralgia, 
which  is  most  noticeable  when  a  storm  is  approaching. 
For  the  past  two  weeks  the  scalp  has  been  exquisitely 
tender  and  the  hair  has  come  out  freely  in  combing  it. 
At  present  her  headaches  are  mostly  occipital.  She  is 
frequently  troubled  with  unilateral  flushings  of  the  face 
(left  side) ,  accompanied  by  dizziness  and  vertigo. 

The  vasomotor  neuroses  are  such  complex  phenomena 
that  a  correct  appreciation  of  the  vasomotor  nerves  and 
their  physiological  action,  as  well  as  the  anatomy  and 
physiology  of  the  arteries  with  which  they  are  connected, 
is  essential  to  their  proper  understanding. 

Dr.  Charles  N.  Smith,  in  an  article  on  "  Vasomotor  Neu- 
roses of  Pelvic  Origin"  in  the  American  Journal  of 
Obstetrics,  November,  1890,  says  that  "  arteries  over  one 

one-hundredth  of  an  inch  in  diameter  have  walls  com- 
5 


VASCULAR    REFLEX    NEUROSES.  65 

eight  days  befote  menstrual  period,  and  was  coincident 
with  an  attack  of  leucorrhoea.  Has  also  occurred  from 
three  to  eight  days  before  menstrual  period.  Her  face  is 
pale  at  first,  but  gradually  gets  red  until  most  of  right  side 
is  extremely  so,  the  left  side  remaining  pale.  The  redness 
disappears  as  the  menstrual  flow  comes  on. 

Nervous  Unilateral  Flushings  and  Indigestion. — 
Mrs.  A.  Z.  (see  plate,  Fig.  5),  27  years  of  age,  has  had 
two  children.  She  is  extremely  nervous,  especially  after 
a  hearty  meal.  When  digestion  is  slow,  as  it  usually  is,  it 
is  generally  accompanied  by  palpitation  of  the  heart.  She 
had  malaria  when  in  the  country  five  years  ago.  She  was 
well  up  to  that  time.  Her  indigestion  is  accompanied  by 
flatulence  and  eructations,  but  these  are  not  very  severe. 
Two  weeks  ago  she  was  seized  with  a  very  severe  head- 
ache. This  was  similar  to  those  she  had  had  at  every 
menstrual  period  for  the  past  five  years.  Occasionally  a 
period  is  not  accompanied  by  this  headache,  but  if  so  the 
headache  is  much  worse  at  the  next  period.  They  are 
migrainous  in  character  and  are  generally  located  in  the 
right  temple.  At  times  she  suffers  from  severe  gastralgia, 
which  is  most  noticeable  when  a  storm  is  approaching. 
For  the  past  two  weeks  the  scalp  has  been  exquisitely 
tender  and  the  hair  has  come  out  freely  in  combing  it. 
At  present  her  headaches  are  mostly  occipital.  She  is 
frequently  troubled  with  unilateral  flushings  of  the  face 
(left  side),  accompanied  by  dizziness  and  vertigo. 

The  vasomotor  neuroses  are  such  complex  phenomena 
that  a  correct  appreciation  of  the  vasomotor  nerves  and 
their  physiological  action,  as  well  as  the  anatomy  and 
physiology  of  the  arteries  with  which  they  are  connected, 
is  essential  to  their  proper  understanding. 

Dr.  Charles  N.  Smith,  in  an  article  on  "Vasomotor  Neu- 
roses of  Pelvic  Origin"  in  the  American  Journal  of 
Obstetrics,  November,  1890,  says  that  "arteries  over  one 

one-hundredth  of  an  inch  in  diameter  have  walls  com- 
5 


66  FUNCTIOXAL    XERVOUS    DISOEDERS. 

posed  of  an  internal,  middle,  and  external  coat.  The  in- 
ternal coat  is  of  the  same  structure  throughout  the  whole 
arterial  system,  irrespective  of  the  size  of  the  vessel.  It  is 
thin,  elastic,  and  identical  in  structure  with  the  endocar- 
dium. The  external  coat,  of  white,  inelastic  fibrous  tissue, 
varies  but  little  in  structure  in  the  three  sizes  of  arteries. 
The  structure  of  the  middle  coat,  however,  is  found  to  vary- 
considerably  with  the  size  of  the  vessel.  In  the  arteries 
of  largest  size  the  middle  coat  is  formed  almost  exclusively 
of  yellow  elastic  tissue,  with  but  few  muscular  fibres. 
This  middle  coat  gives  to  these  largest  vessels  great  elas- 
ticity ;  but,  owing  to  the  absence  of  muscular  fibres,  they 
possess  little  or  no  contractility.  In  the  medium-sized 
arteries  the  yellow  elastic  tissue  gradually  disappears,  its 
place  being  taken  by  muscular  fibre.  In  the  arteries  of 
smallest  size  no  j^ellow  elastic  tissue  whatever  is  found,  it 
having  been  entirely  replaced  by  muscular  fibre.  In 
arteries  less  than  one  one-hundredth  of  an  inch  in  diameter 
the  inelastic  external  coat  disappears,  leaving  but  two 
coats  in  the  vessel  wall — the  internal,  and  an  external 
formed  entirely  of  muscular  tissue. 

"  It  will  be  seen,  then,  that  the  principal  difference 
between  the  three  sizes  of  arteries  lies  in  the  middle  coat, 
and  that,  while  the  largest  arteries  have  practically  no 
muscular  fibres,  these  fibres  increase  in  number  as  the 
arteries  diminish  in  size,  until  they  alone  form  the  whole 
of  this  coat.  This  muscular  tissue  is  of  the  unstriped  or 
involuntary  variety,  arranged  in  circular  fibres  surround- 
ing the  vessel,  with  a  few  fibres  arranged  in  a  longitudinal 
manner.  The  presence  of  these  circular  muscular  fibres 
gives  to  the  arteries  of  medium  and  smallest  size  great 
contractility — a  power  not  possessed  by  the  largest-sized 
arteries.     By  relaxation  of  these  fibres  the  arteries  are 


VASCULAK    KEFLEX    NEUEOSES.  67 

dilated  to  their  widest  extent,  allowing  a  correspondingly 
increased  amount  of  blood  to  pass  through  them.  By  con- 
traction of  the  fibres  the  lumen  of  the  arteries  can  be  so 
narrowed  that  but  a  limited  amount  of  blood  can  circulate 
through  them. 

"  The  contraction  and  dilatation  of  these  muscular  fibres 
are  regulated  by  nerve  ganglia  and  fibres  known  as  the 
vasomotor  ganglia  and  nerves.  In  the  arteries  of  largest 
size,  there  being  no  muscular  tissue,  we  find  no  nerve  fibres 
distributed  to  their  walls,  although  the  nerves  follow  them 
in  their  course.  The  arteries  of  medium  and  smallest  size, 
however,  receive  an  abundant  nervous  supply,  the  nerves 
passing  to  the  circular  muscular  fibres. 

"  The  vasomotor  fibres  and  ganglia  in  the  arterial  walls 
receive  their  stimulation  through  non-medullated  nerve 
fibres  coming  to  them  from  the  sympathetic  nervous  gan- 
glia. Physiological  experiments  have  proven  that  these 
fibres  are  not  derived  from  the  sympathetic  ganglia,  but 
are  communicating  fibres  from  the  cerebro-spinal  system. 
These  fibres  are  of  two  kinds,  each  capable  of  conveying  a 
distinct  impulse.  One  conveys  a  motor  impulse  to  the 
vasomotor  ganglia,  resulting  in  a  contraction  of  the  arterial 
walls,  while  the  other  conveys  an  impulse  which  inhibits 
the  action  of  the  vasomotor  ganglia  and  allows  the  arterial 
walls  to  relax.  The  former  are  known  as  the  vaso-con- 
strictor,  and  the  latter  as  the  vaso-dilator,  nerves. 

"  Under  normal  conditions  the  vasomotor  nerves  maintain 
the  arteries  in  a  condition  of  partial  contraction  or  tone. 
They  regulate  the  amount  of  blood  to  a  part  by  causing  a 
contraction  or  dilatation  of  the  vessels,  according  as  the 
part  requires  a  diminished  or  an  increased  amount  of  blood. 
In  this  action  the  vaso-dilator  nerves  are  the  most  active. 

"  The  centre  presiding  over  these  nerves  is  in  the  medulla. 


68  FUNCTIONAL   NERVOUS    DISORDERS. 

in  the  floor  of  the  fourth  ventricle.  This  centre,  in  turn, 
receives  stimulating  and  inhibitory  impulses  from  the 
cortex.  The  medullary  centre  is  reinforced  by  centres 
situated  in  the  spinal  cord  and  in  the  sympathetic  ganglia. 

"  Contraction  of  the  arterial  walls  can  result  from  but  one 
cause,  that  being  a  motor  impulse  sent  to  the  vasomotor 
ganglia  over  a  vaso-constrictor  nerve.  Dilatation  of  an 
artery,  however,  can  result  from  two  causes,  namely,  a 
failure  on  the  part  of  a  vaso-constrictor  nerve  to  convey  its 
normal  impulse,  allowing  the  artery  to  become  dilated  by 
blood  pressure,  or  from  a  vaso-dilator  impulse  inhibiting 
the  action  of  the  vasomotor  ganglia,  while  the  vaso-con- 
strictor impulse  is  present  but  rendered  inoperative. 
Vaso-constrictor  impulses  are  constant,  while  vaso-dilator 
impulses  are  intermittent, 

"  In  addition  to  these  centrifugal  constrictor  and  dilator 
fibres,  which  emerge  from  the  spinal  cord  by  the  anterior 
or  motor  nerve  roots,  there  are  other  fibres,  entering  the 
cord  by  the  posterior  roots,  which  convey  centripetal  in- 
fluences to  the  spinal  vasomotor  centres.  The  sensory  im- 
pulses so  carried  to  the  centres  provoke  reflex  motor  action 
resulting  in  either  contraction  or  dilatation  of  the  arteries 
at  the  periphery.  Sensory  impulses,  resulting  in  reflex 
motor  action,  may  also  reach  the  vasomotor  reflex  centres 
through  the  sensory  nerves  of  the  cerebro-spinal  system. 

"In  vasomotor  neuroses  either  one  of  two  conditions 
may  occur.  There  may  be  a  spasm  of  the  arteries,  owing 
to  an  excessive  vaso-constrictor  impulse,  and  resulting  in 
a  greater  or  less  diminution  in  the  blood  supply  to  the  part 
supplied  by  the  constricted  arteries;  or  there  may  be  a 
relaxation  of  the  vessels,  allowing  an  increased  blood  supply 
to  the  parts.  This  arterial  dilatation  may  be  active  or 
passive.     In  active  dilatation  the   vaso-constrictor  nerve 


VASCULAR    EEFLEX    NEUEOSES.  69 

still  conducts  its  normal  stimulus  to  the  vasomotor  ganglia, 
but  its  effect  on  the  ganglia  is  overbalanced  by  the  inhibi- 
tory action  of  the  vaso-dilator  nerve.  In  passive  dilatation 
the  vaso-constrictor  nerve  fails  to  convey  its  stimulus  to 
the  ganglia,  either  from  disease  of  the  centres  or  of  the 
nerve  itself,  which  allows  the  arteries  to  be  dilated  by  blood 
pressure.  This  last  condition  is  one  of  vaso-constrictor 
paralysis.  In  addition  to  these  two  conditions  of  spasm 
and  of  relaxation,  there  may  be  an  alternation  of  excessive 
constrictor  and  dilator  influences,  resulting  at  one  time  in 
spasm  and  diminished  blood  flow,  and  at  another  in  dila- 
tation and  excessive  blood  flow. 

"  Prolonged  spasm  of  the  arteries  gives  rise  to  marked 
local  symptoms  and  is  soon  followed  by  decided  nutritive 
changes.  The  parts  supplied  by  the  contracted  arteries 
are  pale,  cold,  and  numb.  The  skin  is  shrunken  and 
wrinkled.  Slight  tingling  sensations  are  felt.  Ansesthe- 
sia  may  be  present  to  a  greater  or  less  extent.  Gradually 
the  nutrition  of  the  part  becomes  defective,  and  atrophy 
with  impairment  of  fimction  follows.  Nutrition  may  suf- 
fer to  so  great  an  extent  as  to  produce  ulceration  or  gan- 
grene. 

"  The  effects  produced  by  prolonged  dilatation  can  be  di- 
vided into  primary  and  secondary.  The  primary  effects 
are  a  red  or  mottled  appearance  of  the  skin,  associated 
with  increased  temperature,  both  subjective  and  objective, 
increased  secretion  by  the  part,  slight  hypersesthesia,  and 
rapid  increase  in  nutritive  changes.  These  primary  con- 
ditions are  later  followed  by  secondary  changes,  owing  to 
the  sluggish  circulation  through  the  widely  dilated  vessels. 
The  hot,  red  surface  becomes  cold,  blue,  cedematous,  and 
clammy,  although  the  subjective  heat  remains.  Nutrition 
suffers  and  function  becomes  impaired.     In  the  mixed  or 


70  FUNCTIONAL   NERVOUS    DISORDERS. 

alternating  form,  heat  and  cold  follow  one  another  in  rapid 
succession.  The  part  is  alternately  flushed  and  pallid,  and 
at  times  bathed  in  profuse  perspiration. 

"  Turning  our  attention  to  the  pelvic  organs,  it  is  seen 
that  the  uterus,  tubes,  and  ovaries  are  richly  supplied  with 
nerves,  both  from  the  sympathetic  and  cerebro-spinal  sys- 
tems, while  important  nerve  trunks  and  plexuses  ramify 
freely  in  the  cellular  tissue  surrounding  them.  When  we 
consider  the  injuries  and  diseases  to  which  these  important 
organs  and  the  surrounding  tissues  are  subject,  we  can 
scarcely  fail  to  realize  how  seriously  they  must  at  times 
involve  the  nerves  here  distributed.  As  is  well  known, 
injury  to,  or  irritation  of,  the  pelvic  nerve  trunks  and  fila- 
ments is  often  followed  by  reflex  disturbances  in  distant 
parts  of  the  body.  Irritation  of  pelvic  nerves  carrying  im- 
pulses to  the  vasomotor  centres  is  followed  by  vasomotor 
disturbances,  not  only  in  the  pelvis,  but  also  in  distant 
parts  as  well."  Dr.  Smith  relates  the  following  cases  which 
demonstrate  how  active  the  injuries  and  diseases  of  the 
female  pelvic  organs  are  in  causing  reflex  vasomotor 
neuroses. 

"Case  I. — Mrs.  A.,  married,  age  28,  consulted  me  in 
1888.  Previous  to  the  birth  of  her  first  and  only  child,  in 
1883,  her  health  had  been  of  the  best.  Labor  was  tedious 
and  terminated  by  forceps.  Two  weeks  after  confinement 
she  was  attacked  by  pelvic  peritonitis,  confining  her  to  bed 
for  six  weeks  and  to  the  house  about  three  months.  Grad- 
ually strength  and  health  returned,  and  her  usual  light 
household,  duties  were  resumed,  although  she  was  never 
free  from  leucorrhoea,  backache,  and  slight  intermittent 
pelvic  pain.  About  one  year  after  confinement  her  right 
arm  began  to  show  signs  of  increasing  weakness.  There 
was  a  subjective  feeling  of  coldness  in  the  arm  and  hand, 
and  on  exposure  to  cold  this  feeling  was  so  intensified  as 


VASCULAR    REFLEX    XEUROSES.  71 

to  become  exceedingly  painful.  Numbness  and  tingling 
sensations  were  often  present.  Gradually  tbese  symptoms 
grew  more  intense,  until  the  arm  became  nearly  useless. 
For  two  years  she  was  treated  for  muscular  rheumatism, 
but  of  course  with  no  benefit.  At  the  time  of  her  first 
visit  to  me  the  arm  was  pale  and  cold  and  the  skin 
shrunken.  Measurements  over  the  middle  of  the  biceps 
showed  the  arm  to  be  one  and  one-fourth  inches  less  in  cir- 
cumference than  the  left.  Weakness  was  so  marked  that 
it  was  impossible  to  raise  the  arm  to  the  head  and  retain 
it  there  long  enough  to  do  up  the  hair.  Not  even  a  light 
weight,  as  a  glass  of  water,  could  be  safely  carried  in  the 
right  hand.  The  arm  was  habitually  carried  flexed  at  the 
elbow  and  drawn  across  the  hodj,  as  if  in  a  sling.  Severe 
attacks  of  numbness  were  frequent.  Repeated  careful 
trials  failed  to  detect  even  the  slightest  pulsation  in  the 
radial  artery  at  the  wrist.  After  my  failures  to  find  radial 
pulsation  the  patient  informed  me  that  within  the  past 
year  two  other  physicians  had  also  failed  to  find  pulsation. 
Pulse  in  left  radial  strong  and  natural.  Patient  is  positive 
that  she  formerly  had  pulsation  in  right  radial. 

'•'  Examination  of  the  pelvic  organs  disclosed  a  bilateral 
laceration  of  cervix  extending  high  up  to  cervico-vaginal 
junction.  A  large  amount  of  cicatricial  material  was 
present.  The  cervix  was  slightly  eroded.  A  slight  chronic 
general  endometrits  was  present. 

"  Recognizing  the  case  to  be  one  of  vasomotor  neurosis  of 
the  spasmodic  variety,  and  believing  that  it  was  of  reflex 
origin  from  pelvic  disease,  I  advised  immediate  treatment 
for  the  endometritis,  to  be  followed,  as  soon  as  practicable, 
by  repair  of  the  lacerated  cervix.  This  was  readily  con- 
sented to,  and  as  soon  as  the  endometritis  was  suflBciently 
relieved  I  successfully  repaired  the  cervix.  Within  two 
months  after  the  operation  the  arm  began  to  show  signs  of 
improvement,  and  within  six  months  a  fairly  strong  pulse 
was  discernible  in  the  radial.  The  coldness,  pallor,  and 
numbness  disappeared,  strength  fully  returned,  and  to- 
day, two  years  after  operation,  the  right  arm  has  as  great 


72  FUXCTIOXAL    XERTOUS    DISOEDERS. 

a  circumference  at  all  points  as  the  left.  Xo  difference 
can  be  detected  in  the  strength  of  the  pulse  in  the  two 
arms. 

"  Case  II. — Mrs.  B.,  age  40.  consulted  me  in  ISS?  for  the 
relief  of  growing  weakness  in  both  legs,  associated  with 
numbness,  tingling  sensations,  coldness,  and  pallor  of  the 
surface.  The  sensation  of  coldness  was  extremely  annoy- 
ing, obliging  her  to  sit  with  feet  and  legs  near  the  fire 
nearly  all  of  the  time,  even  in  warm  weather.  The  legs 
were  so  weak  that  she  required  assistance  in  ascending  or 
descending  a  flight  of  stairs,  and  could  not,  on  a  level  sur- 
face, walk  a  greater  distance  than  two  short  blocks.  These 
troubles  had  been  present  for  about  two  years,  and  had 
gradually  increased  in  severity.  She  has  been  confined 
four  times,  the  last  being  a  miscarriage,  at  the  sixth  month, 
in  1882.  Examination  showed  a  single  deep  laceration  of 
the  posterior  lip  of  the  cervix,  with  the  formation  of  con- 
siderable cicatricial  tissue.  Firm  pressure  in  angle  of 
laceration  caused  slight  pain  and  tingling  in  legs.  A 
slight  cervical  endometritis  and  erosion  were  present. 
Diagnosis :  Vasomotor  neurosis,  spasmodic  variety,  of  re- 
flex uterine  origin.  The  endometritis  was  relieved  by 
treatment,  and  the  laceration  then  closed  by  operation. 

'"'  Xo  marked  change  in  the  condition  of  the  legs  was 
apparent  for  nearly  six  months,  when  improvement  com- 
menced and  progressed  gradually  to  complete  relief  of  con- 
strictor symptoms  in  legs  within  eighteen  months  after 
operation.  The  legs  are  now  strong,  enabling  her  to  per- 
form her  usual  household  duties,  to  ascend  and  descend 
stairs  unaided,  and  to  walk  long  distances  without  especial 
fatigue. 

"Case  III. — Mrs.  C,  age  30,  confined  but  once,  that  in 
1883,  consulted  me  in  1888.  She  was  suffering  from 
chronic  catarrhal  salpingitis  and  chronic  general  endome- 
tritis. The  symptoms  of  salpingitis  and  endometritis  dated 
back  about  three  years.  For  the  past  six  months  she  had 
been  greatly  annoyed  by  rapid  alternation  of  hot  and  cold 
sensations  extending  over  the  whole  body,  but  especially 


TASCUXAK  KEIIEX  STEHBOSES,  73 

marked  on  the  abdomen,  head,  and  shc:;ller5  Lir  i^g 
the  hotflush^  the  skin  became  intense!"  ciiri:-:  sni 
was  bathed  in  pfFofose  perspiraticjn.  Th::-  .rl  ::  i.  "&,= 
soon  followed  bj  coldness  and  pallor  cf  :ir  ~;i„-  jir^s. 
These  conditions  were  identical  with  thosr  :::^:i  :  Sc:~^i 
at  the  menopanse.  Menstruation,  howeverj  was  reguiar. 
and  is  so  stilL 

*'  This  was  plainly  a  case  of  Tasomofcor  neorosis  of  the 
mixed  or  alternating  variety.  That  it  was  'f  z<el-ri  -  zzz  r:^: 
is  clearly  proven  by  the  fact  that  as  the  ss^j  i^^i::-  .1 1  -  - 
dometritis  improved  nnder  treatment  the  "-  -  r:i :  ~  r  ^rr . :  - 
toms  disappeared.  She  has  now  been  en::-"  :r^^  rr»:.m^ 
these  vascular  distnrbanc^  for  aboat  one     -i.: 

"  The  striking  similarity  between  the  neorosal  symptoms 
presented  in  the  last  case  and  those  observed  at  the  meno- 
pause, naturally  leads  one  to  consider  whether  or  not  the 
climacteric  hot  jSoshes  and  their  attendant  conditions  are 
not  results  of  a  vasomotor  neurosis.  I  am  very  decidedly 
of  the  belief,  and  in  that  belief  I  hold  but  that  of  many 
otkers,  that  the  hot  Pushes,  the  sudd^i  alternations  of  heat 
and  cold,  of  blu^  and  pallor,  and  the  local  and  general 
sweating,  occurring  at  the  menopause,  are  the  results  of 
a  vasomotor  neurosis  of  the  mixed  or  alternating  variety, 
and  generally  of  pelvic  origin.  That  these  disturbances 
are  of  the  vascular  system  needs  no  demonstration.  That 
they  are  of  pelvic  origin  is  shown  by  the  report;  of  Case 
III.,  where  the  relief  of  the  pelvic  trouble  was  followed  by 
disappearance  of  vascular  symptoms  identical  with  those 
occurring  at  the  menopause.  FurthCT",  following  artiScial 
production  of  the  menopause  by  removal  of  the  tubes  and 
ovarii,  we  frequently  see  the  -arne  "£.i:alar  disturbances 
as  occurred  in  Case  HI.  and  =~  : :: ::  •;  'Lr  menopause. 
In  these  cases  of  oj^eEation  the  f : r : ^  I  . .  -  :: : n  of  function 
of  ihe  pelvic  organs,  and  the  ch&n^  -  —  n:  :n  take  place  in 


74  FUNCTIONAL    NERVOUS    DISORDERS. 

the  structures  remaining  after  operation,  are  sufficient  to 
produce  the  neurosis. 

"  At  the  menopause  the  generative  organs  undergo  con- 
siderable change  of  an  atrophic  nature,  and  their  function 
is  abolished.  The  changes  in  the  organs  are  surely  suffi- 
cient to  set  up  reflex  nervous  derangements  resulting  in 
vascular  disturbance.  Of  course  it  is  within  the  realm  of 
possibilities  for  these  vascular  disturbances  to  be  of  a  ner- 
vous origin,  independent  of  the  changes  in  the  pelvic 
organs;  but,  in  my  opinion,  such  an  origin  is  rare  as 
compared  v^^ith  the  frequency  of  a  pelvic  origin. 

"  That  the  vasomotor  neuroses  of  the  menopause  may  be 
aggravated  or  caused  by  pre-existing  pelvic  disease  is  un- 
doubtedly true.  It  is  equally  true  that,  as  severe  neu- 
roses occur  at  this  time  in  women  whose  pelvic  organs  are 
not  only  healthy  but  have  been  all  through  life,  they  show 
that  the  climacteric  changes  are  in  themselves  sufficient  to 
produce  these  peculiar  disturbances.  I  have  made  re- 
peated local  examinations  in  a  number  of  such  cases,  and 
failed  to  find  any  abnormal  conditions  of  the  pelvic  viscera. 
It  is  possible  that  in  some  of  these  cases  the  vascular  dis- 
turbances were  occasioned  by  disease  or  derangements  out- 
side of  the  pelvis.  Careful  questioning  and  examination 
of  the  patients,  however,  failed  to  show  such  disease  or 
derangement  in  other  parts  of  the  body.  The  fact  that 
these  vasomotor  disturbances  subside  after  the  climacteric 
changes  are  complete,  argues  very  strongly  in  favor  of  a 
pelvic  origin." 

On  the  other  hand,  however,  there  may  be  cases  of  vaso- 
motor neuroses  of  the  menopause  which  are  not  directly  of 
pelvic  origin,  but  owe  their  existence  to  the  unbalanced 
condition  of  the  nervous  system.  W.  J.  Conklin,  M.D., 
in  a  paper  on  "Some  Neuroses  of  the  Menopause,"  read 


VASCULAR    REFLEX    XEUROSES.  75' 

before  the  American  Association  of  Obstetricians  and, 
Gynsecologists  in  1889,  says:  "The  cases  are  not  few  in 
which  the  neurotic  affections  exist  independently  of  all 
complicating  disorders  of  the  sexual  or  other  organs  of  the 
body,  the  peculiar  nervous  instability  of  the  menopause 
being  alone  responsible  for  the  symptoms.  Perhaps  it  may 
not  be  amiss,  in  an  association  where  every  disease  is, 
viewed  throrigh  gynaecological  spectacles,  to  suggest  that 
in  some  cases  the  pelvic  symptoms  themselves  are  caused 
by,  not  the  cause  of,  the  nervous  disorders.  The  vicious 
circle  begins  in  the  nerve  centres,  not  in  the  pelvic  viscera. 
To  ignore  this  fact  and  consider  the  latter  alone  is  to 
wholly  misinterpret  the  neurosis." 

The  Pulse. 

In  nervous  and  hysterical  women  the  pulse  is  something 
which  especially  claims  our  attention.  In  very  many  we 
find  it  rapid — an  increase  of  from  twenty  to  forty  beats 
above  the  normal,  even  in  cases  where  the  patient  is  not 
exercising. 

At  the  New  York  Mother  Home  Maternity  Hospital,  I 
have  noted  at  a  single  visit  that  one  patient  would  have  a 
pulse  of  52  to  the  minute,  and  in  the  patient  beside  her  the 
pulse  would  range  from  100  to  120.  In  neither  of  these 
patients  would  there  be  any  form  of  pathological  disturb- 
ance, except  some  slight  perturbation  of  the  nervous  system 
resulting  from  the  strain  of  the  labor. 

Miss  E.  B. ,  ;et.  20,  has  just  recovered  from  a  severe  attack 
of  chlorosis  by  the  use  of  pil.  Blaud  cum  gentian.  Since 
early  childhood  has  been  subject  to  fainting  spells;  would 
tumble  over  in  the  middle  of  a  meal,  and  after  being 
sprinkled  with  cold  water  would  get  up  and  finish  it  with 
good  appetite.     Lately  it  has  been  noticed  that  during  the 


76  FUNCTIONAL   NERVOUS    DISORDERS. 

fainting  attacks,  which  are  always  preceded  by  dizziness 
and  an  intensely  sick  stomach,  there  is,  at  times,  redness 
(amounting  to  a  bright  flush)  of  the  face,  while  in  other 
attacks  there  is  marked  pallor.  The  extremities  are  "  cold 
as  ice."  The  attacks  are  always  preceded  by  heart  palpi- 
tation ;  heart  sounds  are  normal ;  digestion  is  weak. 
Whenever  chicken  salad  is  taken,  a  fainting  attack  is  cer- 
tain to  come  on  after  a  short  time. 

Vasal  Weakness  in  the  Left  Side. — Mrs.  M.  J.  P.,  set. 
32,  weight  234  pounds,  of  medium  height.  Has  been  ail- 
ing for  seven  or  eight  years,  but  has  been  worse  for  a  year 
past.  Has  no  appetite.  Distress  after  meals.  Feels  com- 
fortable only  when  her  stomach  is  empty ;  has  "  blue  fits" 
and  crying  spells ;  sleepless  nights  or  horrid  dreams;  suf- 
fers with  numbness  of  the  left  side,  and  the  left  leg,  from 
the  calf  down,  is  swollen  and  extremely  puffy.  She  often 
wakes  up  in  the  middle  of  the  night  with  a  sensation  of 
great  weight  and  numbness  in  the  left  arm,  and  frequent- 
ly feels  with  the  right  hand  to  see  if  the  left  hand  is  there 
(night  palsy,  nocturnal  hemiplegia) .  Has  a  great  deal  of 
pain  in  the  left  side  on  walking;  great  flatulence  of  ner- 
vous origin  after  eating. 

This  disturbance  of  the  left  side  I  have  noted  in  several 
cases  to  be  more  common  than  on  the  right.  It  seems  to 
be  due  to  interference  of  the  ganglia  of  the  sympathetic  of 
the  left  side,  and  also  to  the  presence  of  the  heart  on  that 
side,  as  decidedly  a  great  deal  of  the  stomach  trouble  occurs 
at  the  greater  curvature ;  this  is  the  seat  in  almost  all  cases 
of  the  greatest  amount  of  pain.  Some  patients  also  com- 
plain of  pain  over  the  region  of  the  pylorus.  In  Mrs.  P.'s 
case  any  surprise  or  shock,  such  as  disagreeable  news  or 
sudden  loud  noise,  would  instantl}'  cause  an  attack  of  purg- 
ing and  vomiting,  and  this  would  even  follow  trivial  things 
that  would  be  unnoticed  by  a  person  in  a  fair  condition  of 
physical  health. 


VASCULAR  REFLEX  NEUROSES.  77 

At  the  time  she  came  under  my  notice  she  had  been 
vomiting  blood  regularly  for  three  months  (vicarious  men- 
struation) ,  She  became  very  enthusiastic  over  the  treat- 
ment, and  said  that  from  the  first  she  began  to  improve, 
and  after  a  few  visits  called  herself  well. 

The  treatment  consisted  of  the  usual  restriction  of  diet 
and  tonic  regimen. 

Vasal  Weakness  and  CEdema  Preceding  Each  Men- 
strual Period. — Miss  M.  S.,  aet.  20,  rather  active  temper- 
ament but  not  strong ;  has  the  appearance  of  the  scrof- 
ulous diathesis.  Three  or  four  months  ago,  one  morning 
preceding  her  menstruation,  the  left  hand  was  ice-cold, 
felt  very  heavy,  and  the  whole  arm  ached.  The  next  two 
mornings  the  same  annoying  condition  returned.  In  the 
evening,  usually  about  two  days  before  the  menses  appear, 
the  left  foot  and  leg  become  much  swollen,  accompanied  by 
warmth  and  a  burning  sensation.  This  remains  until  the 
menses  appear;  her  face  also  swells  at  the  same  time  so 
much  as  to  be  very  noticeable.  I  have  seen  her  face 
much  distorted  on  these  occasions  by  oedema  around  the 
eyes  and  at  the  base  of  the  nose.  This  is  a  condition  of 
vasal  weakness  or  temporary  functional  vasal  paresis,  and 
is  not  very  uncommon.  Menses  regular,  last  two  days  and 
a  half;  extremely  painful.  She  feels  so  exhausted  as  to 
imagine  that  a  stroke  from  a  feather  would  annihilate  her. 

Angeio-neurotic  oedema  is  one  of  the  rare  vasomotor 
neuroses.  In  this  disorder  some  disturbance  of  the  vaso- 
motor system  is  the  principal  factor  in  its  causation,  but 
the  cerebro-spinal  system  is  also  implicated.  It  has  been 
said  that  the  cedematous  swelling  is  due  to  paralysis  of  the 
sympathetic,  but  this  alone  is  not  sufficient  for  the  swelling 
of  the  parts.  There  must  be  also  present  an  active  irrita- 
tion of  some  kind.  In  addition  to  this  the  lymphatics, 
veins,  and  arterioles  are  concerned  in  its  production.     It 


78  FUNCTIONAL   NEKYOUS    DISORDEES. 

is  usually  supposed  to  be  a  non-inflammatory  affection  lo- 
cated in  the  connective  tissue  beneath  the  skin  or  mucous 
membrane.  The  oedematous  swelling  is  often  quite  pale, 
while  in  other  cases  it  is  of  a  dark-red  color.  It  does  not 
readily  pit  on  pressure  and  is  usually  without  pain.  It 
generally  comes  on  rather  suddenly  with  some  sensation 
of  tension  in  the  part ;  its  duration  is  indefinite,  lasting 
from  a  few  hours  to  several  days  or  even  weeks. 

Dr.  Joseph  CoUins,  in  his  extensive  study  of  the  disease, 
Bays  that,  as  a  rule,  it  does  not  show  itself  in  more  than  two 
or  three  localities  at  a  single  visit,  and  commonly  only  in 
one.     Sometimes  its  disappearance  in  one  part  is  followed 
by  its  appearance  in  another  at  a  considerable  distance. 
It  may  appear  upon  the  extremities,   face,  or  abdomen; 
less  frequently  upon  the  larynx,  genitals,  and  stomach.    It 
may  occur  in  these  situations  more  often  than  is  generally 
beheved,  on  account  of  the  difficulty  of  diagnosis.     Its 
occurrence  in  any  part  predisposes  to  its  return  in  the  same 
situation.     It  is  not  so  well  understood,  on  account  of  its 
rarity,  as  are  some  of  the  more  common  cedemas,  e.g.,  the 
so-called  menstrual  cedemas.    The  larynx  would  seem  to  be 
a  favorite  spot  for  its  development,  on  account  of  its  being 
so  much  exposed  to  the  influence  of  a  cold  or  a  vitiated 
atmosphere.     It  is  said  to  arise  more  commonly  in  parts 
which  have  been  the  seat  of  an  injury  or  of  an  inflamma- 
tion such  as  erysipelas.     It  may  be  produced  by  a  sudden 
cooling  of  the  body  such  as  occiu-s  in  passing  from  a  heated 
room  into  the  cold  air  without  being  sufficiently  protected 
by  extra  clothing.     This  was  noted  in  one  of  my  cases, 
that  of  a  gentleman  who  left  a  heated  ball-room  and  rode 
a  considerable  distance  in  a  cold  horse-car  with  the  extra 
protection  of  only  alight  spring  overcoat.     The  attack  in 
this  case  was  limited  to  the  larynx,  and  was  of  so  severe 
a  character  that  tracheotomy  was  required.     In  another 


VASCULAR   EEFLEX    NEUROSES.  79 

of  my  cases  the  gastro-intestinal  tract  seemed  to  be  the 
seat  of  the  irritation,  which  caused  the  affection  to  mani- 
fest itself  reflexly  in  the  back  of  the  hand.  There  was 
excessive  mental  and  bodily  exhaustion  in  both  these  jDa- 
tients,  and  in  all  my  cases  there  was  mal-digestion.  The 
disease  in  the  larynx  has  been  often  mistaken  for  a  syphi- 
litic manifestation  in  cases  in  which  the  system  was  per- 
fectly free  from  that  disease. 

This  reflex  dermatosis  has  been  variously  termed  giant 
urticaria  or  urticaria  tuberosa,  periodic  swelling,  acute 
idiopathic  oedema,  acute  non-inflammatory  oedema,  acute 
circumscribed  oedema,  Australian  blight,  and  angeio-neu- 
rotic  oedema.  This  disease  is  said  by  some  to  occur  more 
frequently  in  males  than  females,  although  other  authori- 
ties state  that  the  proportion  of  the  sexes  attacked  is  the 
same.  It  is  said  to  be  more  common  in  cold  weather  and 
in  parts  of  the  body  most  exposed  to  the  cold — the  hands, 
face,  and  larynx.  Cases  have  been  reported  as  having 
originated  from  grief  and  anxiety.  Starr  mentions  a  case 
of  this  sort. 

Dr.  Collins,  after  an  extended  and  critical  investigation 
of  this  subject  in  The  American  Journal  of  the  Medical 
Sciences  for  December,  1892,  arrives  at  the  following  con- 
clusions : 

"  1.  That  there  exists  a  variety  of  oedema  attended  by 
such  striking  characteristics  of  its  own  that  we  axe  justi- 
fied in  referring  its  origin  to  the  nervous  system. 

"  2.  The  seat  of  the  manifestation  of  the  lesion  is  prob- 
ably in  those  vessels  and  lymphatics  which  pass  through 
the  corium  to  the  subdermal  tissues. 

"  3.  It  is  probable  that  although  the  lesions  or  the  irri- 
tants on  which  the  disease  is  dependent  may  attack  other 
parts  of  the  system  yet  the  result  directly  appears  through 
the  sympathetic  system 


80  FUNCTIONAL    NERVOUS    DISORDERS. 

"4.  Evidence  concerning  the  bearing  of  trophic  influ- 
ences in  the  production  of  the  disease  cannot  be  produced, 
but  when  trophic  changes  do  occur  they  are  more  plausibly 
attributed  to  the  changes  brought  about  by  the  oft  recur- 
ring oedema,  per  se,  than  to  influences  exerted  through 
the  nervous  system  as  true  tropho-neuroses. 

"5.  It  is  quite  possible  to  believe  that  in  the  future  its 
causation  may  be  attributed  and  shown  to  be  dependent 
upon  products  manufactured  and  ordinarily  disposed  of 
within  the  system,  but  which,  acted  on  by  sinister  influ- 
ences either  inherited  or  acquired,  result  in  the  temporary 
disturbance  of  the  vasomotor  system,  which  is  manifested 
in  various  parts  of  the  body,  depending,  as  does  the 
analogous  condition  of  the  distribution  of  blushing  and 
flushing,  upon  structural  peculiarities  either  central  or 
peripheral,  or  upon  inherent  predilections. 

"  6.  This  condition  has  a  close  relationship  to  the  many 
oedemas  spoken  of,  and  also  a  family  relation  with  many 
of  the  arthropathies  as  yet  not  well  understood,  but  known 
to  be  directly  caused  through  the  agency  of  the  nervous 

system. 

"7.  It  must  be  admitted  from  clinical  evidence  that  the 
affection  in  question  has  a  family  relation  with  other  vaso- 
motor neuroses  such  as  exophthalmic  goitre  and  urticaria." 

It  should  be  remembered  that  oedema  may  be  produced 
artificially  by  the  tying  of  a  ligature  tightly  around  the 
arm,  wrist,  or  ankle. 

In  a  case  of  an  hysterical  woman  who  suffered  from 
oedema  of  the  hand  every  morning  on  rising,  no  cause 
could  be  detected  by  her  physicians  until  it  was  discovered 
that  she  was  in  the  habit  of  placing  a  tight  ligature  upon 
her  wrist  at  night  and  removing  it  before  their  arrival  in 
the  morning. 


CHAPTER  VI. 
PHARYNGEAL  AND   LARYNGEAL  REFLEX  NEUROSES. 

Pharyngitis  and  laryngitis  of  reflex  origin  are  of  quite 
frequent  occurrence.  They  are  often  dependent  upon  stom- 
ach derangement.  Diseased  pelvic  viscera  are  also  com- 
monly recognized  as  the  cause  of  their  production.  Irrita- 
tions of  the  end  organs  of  the  nerA-es,  in  either  the  digestive 
or  reproductive  organs,  start  up  disturbances  in  the  respi- 
ratory tract,  through  the  intimate  connection  of  the  sym- 
pathetic nervous  system  and  the  vagus,  which  closely 
simulate  disease  of  strictly  local  origin. 

I  am  quite  convinced  that  the  reflex  origin  of  these  dis- 
orders is  but  rarely  recognized  by  many  practitioners. 
This  would  seem  to  explain  their  extreme  chronicity  under 
long-continued  local  treatment  of  the  throat.  They  yield 
promptly,  however,  to  the  treatment  of  the  causative  dis- 
order in  the  digestive  or  reproductive  organs.  The  side 
of  the  throat  or  tonsil  which  is  involved  usually  corre- 
sponds to  the  side  of  the  abdominal  or  pelvic  cavity  where 
the  disease  is  most  intense.  Less  often  the  entire  throat 
is  affected.  Many  of  these  attacks  precede  the  menstrual 
flow,  and  they  are  quite  common  in  young  girls.  The 
symptoms  usually  complained  of  are  soreness  extending 
down  the  sides  of  the  throat,  and  pain  of  an  aching  char- 
acter in  the  tonsils  and  pillars  of  the  fauces.  Sometimes 
the  parts  appear  congested,  at  other  times  there  are  no 
local  signs  of  disease. 

6  81 


82  FUXCTION"AL   NERVOUS    DISORDERS. 

Laryngeal  neuroses  frequently  accompany  menstrual 
disturbances,  and  stomach  cough  is  a  well-recognized 
pathological  condition  dependent  upon  chronic  stomach 
disorder.  It  is  of  a  spasmodic  hacking  character  with  no 
local  manifestations  in  the  larynx  except  a  slight  redness 
when  the  attacks  are  severe  and  frequent.  Many  of  these 
coughs  are  dependent  upon  endometritis  and  dysmenor- 
rhoea. 

The  most  severe  reflex  cough  I  ever  heard  was  in  a 
young  girl  approaching  puberty,  and  was  wholly  due  to 
uterine  disease.  During  the  paroxysms,  which  were  of  a 
loud,  dry,  and  barking  character,  the  patient  had  to  be 
held  by  two  men  to  prevent  her  precipitating  herself  upon 
the  floor. 

Laryngismus  stridulus,  a  common  affection  in  weakly 
children,  is  usually  dependent  upon  gastric  disorder.  In 
this  condition  the  alimentary  mucous  membrane  should 
receive  careful  attention.  Small  doses  of  "gray  powder" 
should  first  be  administered,  followed  by  large  doses  of 
strong  tonics,  such  as  citrate  of  iron  and  quinine.  Great 
attention  should  be  given  to  the  diet  and  hygiene  of  the 
patient. 

Angeio-neurotic  oedema  is  of  reflex  origin.  It  is  usually 
dependent  on  digestive  disorder,  and  a  common  location 
for  it  is  the  larynx. 

A  common  symptom  complained  of  by  patients  suffer- 
ing from  digestive  disorder,  is  a  peculiar  sensation  as  if 
from  the  irritation  of  a  hair  lying  upon  one  side  of  the 
pharynx.  Others  with  gastric  disorder  have  a  similar 
sensation  on  the  roof  of  the  mouth. 

Chronic  rhinitis  and  pharyngitis  are  reflex  neuroses 
dependent  upon  imperfect  digestion  and  excretion.  The 
two  are  almost  always  present  in  the  same  patient.     The 


phakynCtEal  and  laryngeal  reflex  neuroses.     ,  83 

treatment  which  is  most  efficacious  is  brisk  purgation  fol- 
lowed by  a  proper  diet  and  regimen. 

In  a  "Note  on  Codeine,"  in  the  Lancet,  Dr.  James 
Braithwaite,  of  Leeds,  says:  "Codeine  seems  to  have  a 
special  action  upon  the  nerves  of  the  larynx;  hence  it  re- 
lieves a  tickling  cough  better  than  any  ordinary  form  of 
opium.  One-half  of  a  grain  may  be  given  half  an  hour 
before  bedtime.  It  was  in  my  own  case  that  I  first  began 
to  use  codeine.  For  more  than  twenty  years,  usually  once 
every  winter,  I  have  been  seized  with  a  spasmodic  cough 
just  before  going  to  sleep,  which  becomes  so  severe  that  I 
am  compelled  to  get  up  and  sit  by  the  fire.  After  an  hour 
or  two  I  return  to  bed  and  am  free  from  the  cough  till  the 
next  winter.  In  other  respects  I  enjoj'^  good  health. 
Many  years  ago  I  found  that  one-half  grain  of  codeine, 
taken  about  two  hours  before  bedtime,  absolutely  stops  the 
attack  and  leaves  no  unpleasant  effect  the  next  morning. 
In  cases  of  vomiting  from  almost  any  cause,  one-quarter- 
grain  doses  of  codeine  usually  answer  exceedingly  well. 
In  the  milder  forms  of  diarrhoea  one-half  to  one  grain  of 
the  drug  usually  answers  most  satisfactorily,  and  there 
are  no  unpleasant  after-effects." 

Dr.  C.  Henri  Leonard,  in  a  paper  in  the  Journal  of  the 
American  Medical  Association,  1892,  discusses  the  ques- 
tion of  the  female  voice  in  sexual  disease,  and  cites  numer- 
ous cases  in  which  uterine  and  ovarian  disease  have  re- 
sulted in  an  impairment  of  the  voice.  In  one  case,  from  a 
high  mezzo  the  range  was  reduced  to  a  contralto,  and  in 
other  cases  the  masculine  tones  were  creeping  in. 

At  the  time  of  menstruation  it  is  claimed  to  be  a 
common  occurrence  for  singers  to  find  changes  in  the 
purity  of  tone  or  range  of  voice.  The  reason  for  this  is 
found  in  the  intimate  connection  of  the  nerves  supplying 


34  FUNCTIOi^-AL   NEKVOUS   DISORDEKS. 

the  vocal  organs  (spinal  accessory)  and  the  uterus  through 
the  medium  of  the  solar  plexus.  Taking  into  considera- 
tion the  fact  that  from  the  lowest  to  the  highest  note  the 
vocal  cords  vibrate  from  five  hundred  and  seventy-two  to 
sixteen  hundred  and  six  times  a  second  in  soprano  singers, 
and  that  there  are  about  a  hundred  muscles  which  must  be 
brought  into  co-ordination  to  produce  perfect  phonation, 
it  is  not  surprising  that  some  slight  reflex  trouble  will 
have  the  result  of  causing  changes  in  the  voice. 

In  confirmation  of  his  ideas  Dr.  Leonard  cites  the  case 
of  a  patient  of  Dr.  Severs,  of  Fort  Wayne,  who  from 
reflex  influences  had  not  spoken  above  a  whisper  for  two 
years.  In  this  case  cure  resulted  from  treatment  of  a 
rectal  trouble. 

The  following  case  is  another  illustration: 

Miss  S.  I.,  aged  50,  had  hysterical  spasm  of  the  oesoph- 
agus, making  it  very  difficult  to  swallow  solid  food. 
The  passage  of  a  bristle  probang,  which  was  allowed  to 
remain  in  the  throat  for  a  short  time,  removed  the  spasm. 


CHAPTER  VII. 
BEONCHIAL   REFLEX    NEUROSES. 

These  usually  take  their  origin  in  a  manner  similar  to 
the  foregoing,  from  lesions  in  the  genitals,  or  in  the  diges- 
tive tract.  Asthmatic  attacks  of  great  violence  often  de- 
pend upon  nasal  polypi  or  congestions  of  the  mucous  mem- 
brane of  the  posterior  nares.  Cases  have  been  reported 
of  nervous  asthma  dependent  upon  uterine  retroflexion. 
Bronchial  hystero-neuroses  of  pregnancy  are  of  common 
occurrence. 

Bronchial  and  cardiac  neuroses  are  often  combined. 
Cheyne-Stokes'  respiration  has  been  noticed  as  a  neurosis 
dependent  upon  pelvic  disease.  Lacerations  of  the  cervix 
set  up  stomach  symptoms  b}^  stimulation  of  the  coeliac 
axis,  and  disordered  action  of  the  heart  and  difficult  breath- 
ing may  be  caused  by  extension  of  the  irritation  along  the 
pneumogastric.  After  the  operation  for  lacerated  cervix 
these  usually  disappear.  Galvanism,  by  its  action  on  the 
uterine  nerves,  sometimes  permanently  checks  the  dyspnoea 
and  heart  palpitation.  The  importance  in  these  cases  of 
carefully  regulated  diet  and  hygienic  exercises  cannot  be 
overestimated. 

Hiccough  may  be  termed  a  respiratory  neurosis,  as  it 
consists  of  sudden  contractions  of  the  respiratory  muscles, 
particularly  the  diaphragm.  The  starting-point  of  irrita- 
tion is  usually  in  the  digestive  tract,  although  it  may  be  in 

the  uterus.     Sometimes  this  is  a  very  severe  ailment,  and 

85 


86  FUNCTIONAL   NERVOUS    DISOKDERS. 

may  produce  death  from  loss  of  sleep  and  exhaustion. 
Among  the  occasional  causes  of  hiccough  are  swallowing 
the  saliva  while  smoking,  or  the  taking  of  solid  food  im- 
mediately afterward.  Renal  and  biliary  calculi  have 
been  ascribed  as  causes  of  hiccough.  It  is  quite  common 
in  patients  who  have  been  drinking  alcoholic  liquors  to 
excess. 

Hiccough  may  be  cured  by  holding  the  breath  as  long  as 
possible,  or  by  taking  several  sips  of  water  without  draw- 
ing a  breath,  which  amounts  to  the  same  thing.  If  this 
should  fail,  a  teaspoonf ul  of  ether  in  a  little  camphor  water 
will  often  arrest  it.  This  is,  of  course,  when  the  hiccough 
is  due  to  gastric  disturbance.  The  cause  of  the  disorder 
should  always  be  ascertained  and  removed. 

Yaivning  is  clearly  a  neurosis,  but  a  trivial  one.  It  is 
commonly  dependent  upon  indigestion  or  pregnancy.  It 
is  generally  supposed  to  be  always  due  to  drowsiness,  and 
to  result  from  a  lessening  of  the  nervous  energy  of  the 
body.  It  might  be  deemed  a  very  simple  affair,  but  it  is 
extremely  common  and  rather  interesting  to  the  practi- 
tioner in  that  it  seems  to  be  communicable ;  when  in  an 
assemblage  one  person  is  seen  to  yawn,  others  follow  the 
action,  or  yawn  at  the  same  time.  They  seem  to  imitate 
each  other  involuntarily.  Yawning  is  probably  "catch- 
ing" upon  the  same  principle  that  squint  and  stammering 
are,  but  it  is  not  so  disagreeable.  It  is  quite  possible  that 
the  unimpregnated  uterus  may  be  implicated  in  the  pro- 
duction of  yawning.  Yawning  from  nervous  exhaustion 
and  fatigue  is  of  centric  origin;  it  is  really  a  cerebro- 
spinal neurosis. 

Sneezing. — Sternutation  is  usually  a  trivial  disorder, 
and  is,  in  a  manner,  similar  to  hiccough.  It  is  a  convul- 
sive motion  of  the  muscles  of  expiration  resulting  from 


BEOXCHIAL    REFLEX    NEUROSES.  87 

nasal  irritation,  by  which  the  air  is  driven  with  a  loud 
and  hissing  sound  through  the  nasal  passages.  It  is  often 
found  present  as  a  neurosis  in  whooping-cough  and  diges- 
tive disorders,  and  especially  when  intestinal  parasites  are 
present,  more  particularly  thread  worms  which  irritate  the 
rectum. 

Any  rectal  irritation,  such  as  that  resulting  from  hem- 
orrhoids, constipation,  or  pruritus,  will  cause  reflexly  not 
only  sneezing  but  intense  irritation,  with  swelling  of  the 
tip  and  alse  of  the  nose.  This  is  particularly  noted  in  chil- 
dren, and  is  a  well-known  sign  of  the  presence  of  worms. 
Severe  attacks  of  sneezing  sometimes  result  from  disorders 
of  menstruation.  There  are  many  patients  with  weakened 
digestive  organs  who  have  attacks  of  sneezing  on  the 
slightest  exposure  of  the  body  to  cold ;  in  these  cases  there 
is  often  set  up  a  vasomotor  paralysis  of  the  nasal  mucous 
membrane,  with  a  very  profuse  watery  secretion,  often 
suflScient  to  thoroughly  soak  a  handkerchief  in  a  very 
short  time.  Treatment  for  these  cases  is  usually  of  a 
tonic  nature — Fowler's  solution,  quinine,  strychnine,  and 
iron,  with  a  careful  rearrangement  of  the  diet,  both  liquid 
and  solid.  The  act  of  sneezing  can  be  stopped  immedi- 
ately by  pressure  with  the  finger  across  the  upper  lip,  thus 
shutting  off  the  blood  supply  to  the  nose  and  reducing  the 
congestion  of  the  mucous  membrane. 

Bronchial  Hystero- Neurosis  of  Pregnancy. — Mrs.  S., 
aged  37,  very  stout  and  flabby.  Third  pregnancy.  Is 
troubled  with  a  severe  cough  coming  on  at  conception, 
lasting  through  the  whole  of  pregnancy  and  disappearing 
after  delivery.  This  has  occurred  in  three  successive  preg- 
nancies. At  other  times  she  is  entirely  free  from  bronchial 
irritation. 


88  FUNCTIONAL   NERVOUS    DISORDERS. 

The  increased  activity  and  growth  of  the  uterus  during 
pregnancy  whenever  any  pathological  conditions  are  pres- 
ent, are  responsible  for  the  frequent  occurrence  of  neuroses, 
and  these  are  looked  upon  not  onlj^  by  the  laity  but  by 
the  profession  as  evidences  of  impregnation. 


CHAPTER  VIII. 
GASTRIC  REFLEX  NEUROSES. 

These  are  exceedingly  commoa.  All  the  symptoms  of 
indigestion  may  depend  upon  morbid  changes  in  other 
organs,  and  disappear  when  the  causative  disorder  is  re- 
moved by  local  treatment.  Many  cases  of  apparent  gas- 
tritis depend  upon  morbid  changes  in  the  reproductive 
organs.  The  most  common  of  these  neuroses  is  the  well- 
known  nausea  and  vomiting  of  pregnancy,  which  is  some- 
times so  severe  as  to  cause  death. 

Among  the  less  important  neuroses  of  the  stomach  is 
the  tympanitic  distention,  the  belching  and  vomiting, 
which  accompany  menstrual  congestion.  Faintness, 
boulimia,  and  anorexia  are  frequently  the  result  of  uterine 
and  ovarian  congestion.  It  is  said  that  the  vomiting  of 
pregnancy  is  simply  a  physiological  neurosis,  but  I  am 
convinced  that  the  physiological  changes  which  take  place 
in  the  uterus  during  pregnancy  would  not  cause  this  reflex 
disturbance  if  the  uterus  and  its  adnexse  were  perfectly 
healthy,  which  among  civilized  women  is  rarely  the]  case. 
I  have  noticed  that  among  women  who  have  apparently 
healthy  reproductive  organs  the  vomiting  in  the  early 
months  of  pregnancy  is  but  slight  and  of  trivial  import- 
ance. Many  cases  of  chronic  gastric  catarrh  are  asso- 
ciated with  endometritis,  but  whether  it  is  a  reflex  neuro- 
sis or  not  is  doubtful ;  at  any  rate,  the  irritation  set  up  by 

the  endometritis  would  not  be  beneficial  to  the  gastric 

89 


90  FUNCTIONAL   NERVOUS    DISORDERS. 

secretions.  In  cases  where  the  endometritis  has  been  re- 
lieved by  curetting  and  other  local  treatment,  the  stomach 
symptoms  have  disappeared. 

In  studying  the  gastro-hystero-neuroses  we  must  give 
due  attention  to  the  function  of  the  portal  circulation  and 
remember  the  morbid  changes  which  take  place  from 
obstructions  to  its  normal  Row.  In  these  cases  stomachic 
remedies  like  pepsin,  nux  vomica,  and  bismuth  are  of  no 
value  in  removing  the  distressing  stomach  symptoms  until 
the  pelvic  disorder  is  relieved  by  appropriate  treatment. 
Small  fibroids  and  polypi  of  the  endometrium  are  also  pro- 
ductive of  symptoms  which  simulate  chronic  gastric  dis- 
ease. 

Induration  of  the  cervix  and  stenosis  of  the  cervical 
canal  start  up  vomiting  and  many  other  forms  of  ner- 
vous disturbance,  such  as  hysterical  trismus,  globus  hyster- 
icus, and  even  catalepsy.  Gaseous  distention  of  the 
stomach  coming  on  as  a  neurosis  of  the  menstrual  period 
may  be  so  severe  as  to  be  accompanied  by  vomiting  and 
pain.  A  very  large  proportion  of  all  gynecological 
patients  suffer  from  this  neurosis.  It  usually  comes  on 
for  a  few  days  before  the  menstrual  flow,  and  is  sympto- 
matic of  the  uterine  congestion  which  precedes  the  flow. 
Many  of  these  cases  are  treated  as  attacks  of  indigestion, 
or  as  a  mild  form  of  gastritis.  The  epigasiric  region  is 
usually  tense,  tympanitic,  and  sensitive  to  pressure. 
There  is  more  or  less  backache,  and  with  the  dysmenor- 
rhoea  there  are  usually  cramps,  pain  in  the  stomach,  and 
congestive  headache.  In  some  cases  the  epigastric  swelling 
may  be  very  marked  and  extremely  painful.  This  usually 
occurs  when  there  is  sudden  suppression  of  menstruation 
from  exposure  to  cold  or  getting  the  feet  wet.  These  gas- 
tro-hystero-neuroses are  dependent  upon  pathological  condi- 


GASTEIC    REFLEX    NEUROSES.  91 

tions  of  the  uterus,  and  are  often  present  in  school  girls 
who  have  morbid  appetites,  with  cravings  for  pickles  and 
chalk.  These  cravings  are  not  the  result  of  chlorosis 
alone,  as  is  often  supposed,  but  in  many  cases  are  depend- 
ent upon  morbid  irritations  resulting  from  puberty  and 
uterine  catarrh.  In  many  of  these  young  girls  a  ravenous 
appetite  accompanies  the  menstrual  congestion,  and  is  a 
result  of  a  morbid  stimulus  taking  its  origin  in  a  diseased 
uterus.  In  other  patients  there  is  complete  anorexia  dur- 
ing the  menstrual  period,  and  all  these  symptoms  disap- 
pear only  upon  relief  of  the  uterine  disease.  Quite  as  fre- 
quently the  uterine  symptoms  are  indications  of  gastric 
or  hepatic  disturbance,  and  very  many  cases  of  uterine 
catarrh  and  endometritis  are  dependent  upon  hepatic 
obstruction. 

A  very  common  reflex  from  gastric  disorder  is  frontal 
headache;  in  fact,  the  great  majority  of  headaches  are  re- 
flex, and  a  large  number  of  them  are  consequent  upon 
gastric  or  hepatic  disturbance,  and  vice  versa.  Neuroses 
of  the  stomach  are  very  frequent  results  of  functional  dis- 
turbance from  disease  in  other  organs.  Fleisher  has  noted 
a  diminution  of  the  secretion  of  hydrochloric  acid  during 
menstruation,  and  Dr.  M.  Gross  reports  the  case  of  a 
neurasthenic  patient  who  was  attacked  after  almost  every 
coitus  with  nausea  and  gastralgic  pains,  sometimes  asso- 
ciated with  vomiting.  The  vomited  matters  always  con- 
tained an  excess  of  free  hydrochloric  acid.  He  also  men- 
tions the  fact  that  there  is  a  condition  of  the  gastric  juice 
known  as  anachlorhydria,  or  nervous  anacidity,  found  in 
neurasthenic  and  hysterical  patients  in  whom  no  organic 
disease  of  the  stomach  is  present.  The  great  importance 
of  the  relations  existing  between  the  gastric  juice  and  the 
diseases  of  other  organs  of  the  body  must  be  recognized. 


92  FUNCTIOXAL   JS'ERVOUS    DISORDERS. 

He  states  that  there  is  scarcely  an  internal  disorder  in 
which  the  gastric  digestion  is  not  largely  implicated  and 
connected  more  or  less  intimately  with  functional  disturb- 
ances.  Dr.  Gross,  in  his  article  "On  the  Connection  be- 
tween Affections  of  the  Stomach  and  Diseases  of  Other 
Organs"  {Neiv  York  Medical  Journal,  May  4th,  1895), 
Bays :  "  A  full  comprehension  of  the  morbid  processes  in 
the  stomach,  of  the  morbid  symptoms  of  disturbed  gastric 
digestion,  cannot  be  obtained  without  considering  the  re- 
lations between  the  stomach  and  the  diseases  of  the  other 
organs  of  the  body ;  for  every  affection  of  the  stomach  is 
■reflected  back  on  the  other  organs,  and  inversely  every 
disease  of  the  organs  reacts  upon  the  stomach."  He  speaks 
chiefly  of  the  circulatory  disturbances  which  lead  to  con- 
gestions, and  their  sequelae  in  diseases  of  the  heart,  the 
lungs,  and  the  liver.  As  a  matter  of  special  importance 
he  points  out  that  in  a  number  of  cases  symptoms  of  dys- 
pepsia precede  the  first  signs  of  phthisis,  and  considers  the 
dyspeptic  troubles  as  the  result  of  venous  hypersemia  and 
•congestion  coming  on  from  the  disturbed  pulmonary  circu- 
lation. The  digestive  complaints  are  to  my  mind  more 
often  the  causative  factors  in  the  production  of  pulmonary 
disease  than  its  results. 

Of  the  various  neuroses  associated  with  uterine  disease, 
particularly  retroflexion  and  the  neuroses  dependent  upon 
it,  the  gastric  neurosis  is  probably  the  most  frequent. 
Often,  however,  we  may  observe  the  persistence  of  the 
gastric  neurosis  in  spite  of  the  cure  of  the  retroflexion. 
Quite  recently,  indeed,  clinical  investigators  have  devoted 
increased  attention  to  the  digestive  disturbances  which 
are  not  due  to  an  organic  disease  of  the  digestive  appa- 
ratus, but  are  based  upon  certain  conditions  of  irritation  or 
atony  of  the  nervous  system.    Every  gynecologist  will  ad- 


GASTRIC    REFLEX    NEUROSES.  93 

mit  that  women  suffering  for  a  long  time  with  sexual  dis- 
eases complain  chiefly  of  associated  gastric  disturbances 
of  a  widely  varying  nature.  In  such  cases  we  have  to 
deal  with  dyspeptic  disturbances  without  organic  altera- 
tions of  the  digestive  apparatus,  in  which  the  diseases  of 
the  uterus  and  its  adnexa  give  rise  to  centripetal  irritation 
of  the  nervous  system,  and  these  in  a  reflex  way  act  upon 
the  digestion.  Thus,  we  often  meet  with  gastralgias  of 
the  most  violent  kind  with  the  onset  of  menstruation.  In 
these  cases  there  may  be  increased  or  continuous  acid  se- 
cretion, which  ceases  after  the  flow.  The  persistence  of 
the  gastric  neuroses  after  the  cure  of  the  uterine  disease  is 
due  (see  Engelmann)  to  a  persistence  of  the  irritation  in 
the  nerve  terminals. 

Gastric  Neuroses  of  Pregnancy. — Gastric  neuroses  de- 
pendent upon  pregnancy  are  exceedingly  common. 

Mrs.  Van  H.,  aged  42,  suffers  from  severe  pain  in  the 
epigastrium,  running  up  to  the  pharynx,  where  it  mani- 
fests itself  as  a  globus  hystericus.  This  comes  on  during 
pregnancy,  and  is  dependent  upon  it,  and  so  marked  is 
this  relation  that  she  says  "  it  comes  on  at  the  A^ery  mo- 
ment of  conception."  She  can  eat  only  a  little  steak  and 
very  light  food  during  the  day;  if  she  eats  more  she 
suffers  much  from  nausea.  She  also  suffers  from  soreness 
in  the  epigastric  region.  The  tongue  is  perfectly  clean, 
and  there  are  no  symptoms  of  gastric  catarrh.  If  she 
drinks  much  liquid,  it  immediately  excites  vomiting. 

These  conditions  in  her  case  always  disappear  immedi- 
ately after  delivery, 

Mrs.  McC,  aged  58,  gastro-enteric  catarrh  and  psy- 
choses. Has  always  been  fairly  well,  but  has  suffered 
from  a  sensation  of  fulness  before  having  had  quite  enough 
to  eat.  Shortly  after  eating  she  eructates  immense  quan- 
tities of  gas.  Her  teeth  are  in  very  poor  condition.  Is 
not  emaciated.     Is  extremely  nervous,  and  without  the 


94  FUNCTIOXAL    NERVOUS    DISORDEKS. 

slightest  provocation  often  gives  way  to  tears.  When  I 
was  first  called  to  see  her  she  was  suffering  from  an  attack 
of  severe  cramps  and  colic  with  extreme  distention  of  the 
bowels.  Sleep  is  generally  undisturbed.  While  out  walk- 
ing she  worries  continually  about  her  home,  and  desires 
to  return  almost  immediately.  Her  daughter,  a  young 
lady  of  eighteen,  is  also  extremely  nervous  and  suffers  in  a 
similar  manner.  In  one  of  her  attacks,  after  fasting  a  long 
time,  she  became  delirious  and  was  insane  for  some  weeks. 
During  this  time  her  stomach  was  so  weak  and  sensitive 
that  it  would  not  contain  even  a  toasted  cracker.  The 
diet  these  two  have  been  living  on  the  past  summer  has 
consisted  of  fried  meats,  fruits,  and  watermelons. 

Hysteric  Suffocation  as  a  Gastric  Reflex  Neurosis. 
• — Miss  Katie  A.,  aged  30,  single,  has  shortness  of  breath. 
Menses  are  rather  scanty.  At  times  she  has  pains  with 
them  which  extend  into  the  thighs.  Slight  leucorrhoea. 
During  attacks  of  hysterical  suffocation  she  feels  like  sob- 
bing. Has  no  cough.  Lungs  and  heart  are  normal.  She 
drinks  four  cups  of  coffee  in  the  morning  and  two  cups  of 
tea  during  the  day.  This  is  a  case  of  hysteric  suffocation 
resulting  from  excessive  use  of  coffee. 

Melancholia  a  Gastric  Reflex  Neurosis. — Mrs.  S., 
aged  32.  Ever  since  her  brother's  death,  which  occurred 
about  six  months  ago,  she  has  been  extremely  low-spirited, 
but  has  been  complaining  off  and  on  for  some  years  past. 
For  the  last  two  or  three  months  suicide  has  always  been 
in  her  thoughts.  She  is  almost  always  in  tears;  her  di- 
gestive organs  are  much  disordered.  She  has  abnormal 
appetites  and  cravings,  and  all  the  food  which  is  ferment- 
able sours  almost  immediately  after  it  has  been  taken. 
Is  always  very  constipated.  She  has  not  left  her  house 
for  weeks  at  a  time.  For  the  past  two  months  has  not  been 
outside  of  the  house,  and,  although  physically  able  to  do 
so,  cannot  be  prevailed  upon  to  take  exercise.  A  car- 
riage was  brought  around  to  the  door  on  several  occasions. 


GASTRIC    EEFLEX    :N"EUE0SES.  95 

and  her  husband  and  friends  insisted  on  her  going  for  a 
ride  to  see  if  it  would  break  up  the  monotony  and  depres- 
sion from  which  she  suffered.  She  immediately  went  to 
bed  and  remained  there,  and  persistently  refused  to  go. 
After  treatment  of  her  digestive  organs  her  condition  im- 
proved. She  was  induced  to  go  shopping  and  on  short 
visits,  and  finally,  after  careful  dieting,  she  recovered 
completely. 

A  good  example  of  a  gastric  uterine  reflex  is  to  be  found 
in  rapid  manual  or  instrumental  dilatation  of  the  cervix, 
which  will  some  times  start  most  violent  reflex  vomiting 
lasting  for  hours.  I  have  in  mind  a  patient  who  had  the 
cervix  dilated  for  the  purpose  of  curettage  of  the  en- 
dometrium. The  result  of  the  instrumental  stretching  of 
the  part  was  to  set  up  a  violent  vomiting  lasting  for  more 
than  twenty-four  hours. 

The  following  case  shows  the  relation  between  digestive 
and  nervous  disorders : 

Mrs.  J.  T.  H.,  aged  31;  nullipara,  married  six  years. 
This  patient  has  always  had  headaches,  and  these  have 
been  of  one  of  two  distinct  types — one  nervous  and  the 
other  migrainous.  The  former  is  situated  at  the  vertex, 
occurs  most  intensely  at  the  menstrual  epoch,  but  is  also 
present  at  other  times.  The  sensation  was  that  of  "a 
splitting  pain  of  the  head,"  and  at  times  it  has  made  her 
delirious.  She  also  has  occipital  headache,  and  this  is  re- 
lieved by  hot  water-bags  or  by  other  forms  of  hot  appli- 
cations to  the  occiput. 

The  second  type,  or  migrainous  headache,  has  been  so 
extremely  severe  that  she  has  been  compelled  to  go  to  bed 
as  soon  as  the  attack  began.  The  pain  is  confined  to  a  spot 
not  larger  than  a  half-dollar.  Nausea  comes  on  with  or, 
■as  is  often  the  case,  precedes  the  headache.  During  these 
attacks  a  numbness  starts  in  various  parts  of  the  extremi- 
ties, with  complete  loss  of  sensation;  as  the  patient  ex- 


96  FUNCTIONAL   NERVOUS    DISORDERS. 

presses  it,  "a  cold,  tingling  numbness."  Sensation  only 
is  abolished ;  motion  is  perfect.  At  these  times  she  is 
much  distressed  by  crawling  sensations  in  the  lower  ex- 
tremities. I  find  that  many  other  women  experience  simi- 
lar disagreeable  sensations. 

Ever  since  she  was  a  young  girl  she  has  lived  in  hotels, 
and  has  indulged  in  all  sorts  of  sweets  and  pastries,  and 
has  at  the  present  time  an  intense  craving  for  candies  and 
fruits.  She  says  constipation  has  existed  ever  since  she 
was  born.  The  menstrual  function  is  regular,  but  is. 
scanty  and  painful.  She  has  occasional  attacks  of  anuria, 
and  suffers  from  a  pure  uterine  neuralgia,  which  is  inde- 
pendent of  menstruation.  Her  tongue  is  heavily  coated. 
She  is  growing  fat,  and  feels  fairly  strong.  She  has  been 
eating  everything  she  craves — all  sorts  of  French  cookery, 
preserves,  cakes,  etc.  At  times  she  has  a  craving  for 
common  potato  starch  and  has  used  it  by  the  five-pound 
box,  eating  it  by  the  handful.  Several  of  her  lady  friends 
have  also  done  this.  She  chews  a  great  deal  of  unground 
coffee. 

This  case  is  typical  of  disordered  conditions  of  the  diges- 
tive organs,  and  secondarily  of  disorder  of  the  uterine  func- 
tions, the  result  of  bad  hygienic  and  dietetic  habits.  To 
correct  this  condition,  attention  must  be  given  to  the 
psychical  condition  of  the  patient.  I  gave  this  lady  the 
following  prescription : 

Inf.  calumbee,  .......  §  ss. 

TiDct.  cinchonaeco. ,         ......  3  ij. 

Sodii  phosphat 3  iij. 

Aq.  menthas  pip. ,    .         .         .         .         .         .         .  §  ij. 

One  teaspoonf ul  in  a  glass  of  hot  water,  half  hour  before  meals. 

I  also  carefully  regulated  her  diet.  She  returned  in 
about  one  week  much  improved  as  regards  the  headache, 
and  her  digestion  was  also  decidedly  better. 

These  morbid  cravings  are  quite  common.     I  have  seen. 


GASTKIC    EEFLEX    XEUROSES.  97 

two  young  girls  who  consumed  daily  one  to  two  ounces  of 
ordinary  table  salt.  In  the  New  York  Magdalen  Asylum 
it  is  very  common  for  the  inmates  to  chew  tea  leaves,  and 
very  strong  coffee  is  frequently  taken  by  them  for  its  stim- 
ulant effect  when  they  cannot  obtain  alcoholic  beverages. 

These  patients  are  not  ohlorotic,  and  hence  these  cases 
are  of  more  than  usual  interest.  It  is  evident  from  this 
case  that  there  is  an  intimate  connection  betw'een  the  dis- 
ordered condition  of  the  digestive  organs  and  that  of  the 
pelvic  organs,  and  indirectly  of  the  nervous  system,  as 
shown  by  the  headaches  from  which  she  suffered. 

I  am  thoroughly  convinced  that  more  attention  should 
be  given  to  the  digestive  functions  by  gynecologists 
generall}^,  and  that  in  a  large  proportion  of  cases  the 
uterine  functions  are  of  but  secondary  importance. 


CHAPTER  IX. 
INTESTINAL   REFLEX  NEUROSES. 

Looseness  of  the  bowels  and  flatulence  are  common  as 
intestinal  hystero-neuroses.  Among  young  girls  diarrhoea 
immediately  preceding  the  menstrual  period  has  been  noted 
in  a  number  of  cases.  There  is,  as  a  rule  increased  intes- 
tinal action  with  hypersecretion  of  the  intestinal  glands, 
following  sexual  connection,  due  to  the  excitement  of  the 
vasomotor  nerves  resulting  from  the  genital  stimulation. 
In  others  there  are  symptoms  of  vesical  weakness  and 
functional  disturbance  of  the  bladder.  In  some  cases  there 
is  diarrhoea  preceding  the  flow,  constipation  during  its 
continuance,  and  diarrhoea  for  a  day  or  two  following  its 
cessation,  and  then  costiveness  during  the  remainder  of 
the  intermenstrual  period,  and  this  regular  succession  of 
events  occurs  at  every  catamenial  epoch.  Vice  versa, 
intestinal  and  rectal  disease  with  much  mucous  discharge 
have  a  weakening  efl'ect  on  the  sexual  powers,  and  impo- 
tence and  barrenness  are  often  reflex  neuroses  dependent 
upon  intestinal  disease.  Intestinal  indigestion,  constipa- 
tion, impaction  of  the  colon  and  chronic  diarrhoea  manifest 
their  presence  frequently  by  reflex  occipital  headache.  A 
loaded  colon  is  a  great  factor  in  producing  reflex  nervous 
symptoms.  When  it  is  emptied,  however,  by  a  brisk 
cathartic,  relief  immediately  follows,  the  reflex  symptoms 
disappearing.     Many  of  the  derrqatoses  are  the  results  of 

fsBcal  impaction.     Chloasmic  spots  may  be  the  result  of  the 

98 


IIS"TESTI]S'AL   KEFLEX    2^EUR0SES.  99 

absorption  of  fsecal  material  and  its  attempted  excretion 
by  the  skin,  or  it  may  be  a  pure  reflex. 

The  improvement  in  the  appearance  of  these  patients 
under  colonic  flushings  and  hepatic  stimulation  is  usually 
well  marked. 

Scybalse,  by  pressure  or  irritation  of  the  ganglionic 
nerves,  frequently  set  up  a  severe  gastralgia. 

Enteralgia  or  colic,  the  result  of  hysteria  or  severe 
mental  excitement,  which  is  probably  a  neuralgia  of  the 
mesenteric  plexus,  is  an  affection  principally  of  the  sym- 
pathetic system. 

The  following  case  of  cerebro-abdominal  neurosis  was 
related  to  me  by  Dr.  M.  Gross: 

The  patient,  a  young  woman,  aged  23,  was  apparently 
in  a  fair  condition  of  health.  A  few  hours  after  witness- 
ing an  accident  to  a  friend  she  was  attacked  by  a  violent 
constant  pain  in  the  bowels,  which  exhibited  marked  ex- 
acerbations; it  seemed  to  be  located  in  the  small  intestine 
as  its  origin  in  the  uterus,  stomach,  and  large  intestine, 
was  readily  excluded.  Menstruation  was  perfectly  normal,' 
the  pain  preceding  its  advent  and  continuing  after  it  had 
disappeared ;  the  stomach  was  not  sensitive  and  the  loca- 
tion of  the  borborygmi  did  not  involve  the  large  intestine. 
There  was  no  abdominal  distention  ;  the  pain  was  located 
in  the  region  of  the  navel  and  gave  the  impression  of  com- 
ing entirely  from  the  small  intestine  and  radiating  toward 
the  back.  She  obtained  slight  relief  only  in  a  stooped, 
sitting  posture.  She  had  been  treated  by  some  lady  phy- 
sicians with  opiates  in  large  doses,  without  any  effect  ex- 
cept to  make  her  sleepless  and  miserable. 

The  neurotic  origin  of  the  distress  being  determined,  Dr. 
Gross  put  her  upon  large  doses  of  the  bromides  with  nearly 
immediate  good  result,  the  pain  being  relieved  in  a  short 
time. 

Attacks  of  pain  of  this  kind  are  allied  to  the  attacks  of 


100  FU]S^CTI02s'AL   ^"EEyOUS    DISOEDERS. 

diarrhoea  and  vomiting  ■which  come  on  from  depressing 
mental  excitement.  Why  the  pain  is  located  at  this  point 
and  not  in  the  uterine  or  cardiac  nerves,  is  an  interesting 
question ;  it  ma}^  be  because  this,  at  the  particular  time  of 
the  attack,  was  the  weakest  part,  or  the  digestion  may 
have  been  arrested  at  this  portion  of  the  digestive  tract 
during  the  excitement.  During  digestion,  there  is  of 
course  a  physiological  congestion  of  the  active  part. 

Intestinal  Reflex  Neuroses — Nervous  Diarrhoea. — 
Miss  Florence  M.,  aged  42,  is  of  an  exceedingly  nervous 
temperament.  Says  she  suffers  constantly,  except  when 
she  takes  boiled  milk,  from  a  watery  painless  diarrhcea. 
When  a  child  she  says  vegetable  food  of  almost  any  de- 
scription gave  her  diarrhoea.  Ever  since,  she  has  lived 
principally  upon  boiled  milk.  Is  extremely  voluble;  is 
very  introspective,  noting  the  most  trifling  variations  in 
her  condition  with  great  care,  and  in  fact  thinks  about 
little  else.  She  is  a  woman  of  good  education,  and  when 
a  young  girl  of  twenty  and  for  some  years  after  was  a 
writer  of  short  stories  for  magazines.  While  engaged  at 
this  work  the  blood  would  leave  her  extremities,  which 
became  extremely  cold,  and  would  collect  in  the  head  and 
face.  At  this  time  the  head  and  neck  would  perspire  Yevy 
freely.  After  completing  her  work  she  was  always  taken 
with  diarrhoea,  which  became  so  severe  that  her  parents 
stopped  her  literary  work.  She  thought  that  the  air  of 
Chicago,  her  home,  did  not  agree  with  her,  as  diarrhoea 
persisted  while  she  remained  there.  At  one  time  she 
lived  from  May  to  October  on  a  large  steamer  which  made 
long  trips  on  the  great  lakes,  and  at  this  time  she  was 
comparatively  free  from  the  diarrhoea.  Drugs  seem  never 
to  have  been  of  benefit.  While  I  have  been  conversing 
with  her,  her  face  is  flushed  and  she  calls  attention  to  the 
extreme  coldness  of  her  hands  and  feet.  She  says  that  she 
could  outline  with  a  pencil,  and  she  sbows  with  her  finger, 
the  areas  of  severe  cold  over  the  ovarian  region,  which 
feel  "as  if  there  were  lumps  of  ice  there."     Fig.  9. 


INTESTINAL   EEFLEX    XEUEOSES.  101 


Fig.  9.— Intestinal  Reflex  Neurosis.     Vasomotor  Disorder. 


103  FUNCTIONAL    NERVOUS    DISORDERS. 

Nervous  Dim^rhoea. — Miss  M.,  aged  28.  When  ner- 
vous from  any  cause,  such  as  a  severe  reprimand  from 
her  father,  or  when  anxious  because  of  his  intoxication, 
or  the  illness  of  her  mother,  who  is  a  chronic  nervous  in- 
valid, she  is  always  taken  with  a  sudden  and  severe  diar- 
rhoea. This  condition  frequently  lasts  for  days.  Bad  news 
of  any  kind  will  bring  on  such  an  attack. 

Nervous  Diarrhoea  and  Mot^bid  Flushings. — Miss  A. 
M.,  aged  33.  Seen  January  27th,  1890.  During  the  past 
summer  she  has  suffered  from  malarial  symptoms,  chills 
and  fever,  and  sweatings.  Had  an  attack  about  one  year 
ago.  Now,  whenever  she  gets  ready  to  go  out,  she  has  an 
attack  of  diarrhoea.  There  is  no  flatulence,  but  simply 
diarrhoeal  evacuations  occur.  Recently  the  attacks  have 
come  on  the  first  three  nights  of  each  week.  They  are  ac- 
companied by  cramps;  her  face  becomes  excessively  red, 
especially  the  nose,  and  she  can  scarcely  see  because  of  a 
mist  which  comes  before  her  eyes.  This  is  an  evidence 
of  a  vasomotor  flushing  of  the  face  and  head.  She  has  also 
some  pain  in  the  left  ovarian  region.  At  times  there  is  a 
frequent  desire  to  urinate,  and  both  urination  and  diar- 
rhoea are  increased  at  the  menstrual  period.  She  has 
monorrhagia  lasting  seven  or  eight  days.  These  morbid 
flushings  cause  her  considerable  annoyance. 

A  few  days  ago  while  she  was  in  a  hairdresser's  chair, 
there  was  a  very  severe  attack  of  morbid  flushing  accom- 
panied by  heat  and  perspiration  (see  Plate  II.,  Fig.  6). 
This  was  so  noticeable  that  the  hairdresser  proceeded  to 
fan  her.  She  has  had  severe  intestinal  cramps,  and  be- 
lieving these  to  be  due  to  a  lack  of  the  natural  intestinal 
secretions  and  to  fermentation,  I  prescribed  Fowler's  solu- 
tion, which  gave  complete  relief.  For  the  nervous  phe- 
nomena the  following  simple  prescription  was  ordered : 

IJ  Potassii  bromidi, 

Sodii  bromidi,        .         .        .        .        .        .      aa   §  ss. 

Syrupi, §  iv. 

Sig.  One  teaspoonful  every  three  hours. 

The  effect  of  the  bromides  was  to  stop  the  monorrhagia, 


INTESTINAL    KEFLEX    NEUROSES.  103 

and  her  menstruation  now  lasts  only  four  days.  For  the 
malarial  complications  which  were  thought  to  be  possibly 
a  powerful  causative  factor,  five  grains  of  quinine  were 
given  three  times  a  day.  This,  she  says,  acted  as  a  brisk 
cathartic.  This  result  I  have  noted  before  in  other 
patients  of  a  nervous  type. 

The  preceding  case  is  one  of  morbid  flushing;  in  fact,  it 
was  for  this  that  she  principally  consulted  me,  although 
the  nervous  diarrhoea  was  also  quite  troublesome. 

The  following,  by  Dr.  John  Hilton,  is  a  good  example  of 
transferred  symptoms.  The  irritation  from  an  anal  ulcer 
is  transferred  probably  through  the  medium  of  the  spinal 
cord  or  through  the  sympathetic  to  other  organs  in  the  ad- 
jacent parts. 

Case  of  Anal  Ulcer  Producing  Retention  of  Urine 
and  Symptoms  of  Pregnancy. — "The  case  is  that  of  a 
young  lady,  aged  about  32,  whom  I  saw  some  years  ago 
with  the  late  Dr.  Golding  Bird.  She  was  an  excellent 
dancer,  good  company  in  a  drawing-room,  and  thought  to 
be  a  very  agreeable  and  attractive  person.  Gradually 
she  receded  from  that  position  in  society,  lying  down 
a  good  deal  on  the  sofa,  suffering  much  pain,  always  un- 
comfortable, occasionally  quitting  the  room,  whether  in 
society  or  at  home  among  her  own  relations.  It  was 
noticed  that  she  had  occasional  sickness,  menstruation  was 
not  regular,  the  abdomen  was  decidedly  increasing  in  size. 
She  became  very  fond  of  lying  in  bed  instead  of  going  to 
balls  and  dances — in  fact,  she  said  she  could  not  dance  or 
enjoy  society  at  all — and  was  very  uncomfortable.  A, 
surgeon  was  consulted,  who,  perceiving  the  patient's 
changed  character,  and  finding  the  lower  part  of  the 
abdomen  decidedly  large  and  prominent,  mentioned  a 
suspicion  of  pregnancy  to  her  mother.  Her  mother, 
who  was  personally  acquainted  with  the  late  Dr.  Golding 
Bird,    took   her  to   him.      He    examined    her   carefully. 


104  PUIS'CTIOXAL   NERVOUS    DISOEDERS. 

and  said:  "She  is  not  in.  the  family  way,  depend  upon 
it;  I  think  the  symptoms  arise  from  piles,  or  something 
wrong  in  the  rectum."  It  was  under  these  circumstan- 
ces that  I  W8.S  requested  to  examine  her.  I  found  her 
suffering  from  piles  and  prolapsed  rectum,  retention  of 
urine  nearly  complete,  enlarged  abdomen,  sickness,  loss  of 
appetite,  constant  pain  at  the  lower  part  of  the  stomach, 
bowels  constipated,  frequent  loss  of  blood  from  the  rectum, 
and  extreme  pain  during  and  after  defecation.  Her  ill- 
ness commenced,  many  weeks  before  I  saw  her,  with  great 
pain  in  passing  a  motion,  and  all  her  urgent  symptoms 
resulted  from  the  original  anal  ulcer.  This  was  the  order 
of  events:  The  nerves  of  the  anus  and  neck  of  bladder 
being  derived  from  the  same  trunk  nerve — the  pudic — the 
nerve  irritation  extended  from  the  anal  ulcer  to  the  mus- 
cles of  the  neck  of  the  bladder  and  urethra.  This  caused 
them  to  contract,  and  produced  difficult}'  in  making  water, 
and  subsequentl}'  the  retention  of  urine.  The  protracted 
distention  of  the  bladder  caused  pressure  upon  the  rectum, 
interfering  with  the  return  of  blood  from  near  the  anus, 
and  this,  added  to  the  straining  of  the  patient  to  relieve 
herself,  caused  distention  of  the  rectal  veins  and  partial 
prolapse  of  the  rectum.  Hence  arose  all  the  other  symp- 
toms to  which  I  have  adverted. 

"  I  passed  a  probe  between  the  projecting  folds  of  the 
rectum,  and  soon  made  out  where  the  ulceration  existed. 
I  removed  a  portion  of  an  external  pile,  and  then  obtained 
a  clear  view  of  it,  situated  just  within  the  anus,  full  half 
an  inch  wide,  and  more  than  three-quarters  of  an  inch  in 
length;  muscular  fibre  formed  its  base.  I  divided  the 
sphincter  muscle  through  the  centre  of  the  ulcerations,  and 
nearly  the  whole  of  the  painful  symptoms  quickly  sub- 
sided, and  the  patient  was  soon  well  and  as  happy  and 
gay  as  ever.  1  have  seen  the  lady  several  times  since,  and 
she  has  remained  perfectly  well." 

Miss  H.,  aged  30,  has  an  enlarged  retroverted  uterus 
with  much  tenderness  and  prolapse  when  evacuating  the 
bowels  and  at  menstrual  periods.     The  pain  was  so  severe 


IXTESTIXAL    REFLEX    XEUE05ES.  105 

that  Alexander's  operation  of  shortening  the  round  liga- 
ments was  proposed  by  a  well-known  Xew  York  gynecolo- 
gist. This  condition  was  accompanied  by  a  severe  form 
of  chronic  indigestion,  and  the  patient  was  extremely 
aneemic  and  worried.  She  went  to  the  country  for  the 
summer,  and  returned  in  the  fall  in  perfect  health,  not 
having  taken  in  the  mean  time  any  medicine  or  submitted 
to  any  operation.  This  case  exemplifies  the  fact  that 
many  cases  of  uterine  disease  are  dependent  on,  or  aggra- 
vated by,  the  disturbance  of  the  digestive  organs.  This  is 
undou?jtedly  true  of  dysmenorrhcea.  If  we  succeed  in 
strengthening  the  patient  and  curing  the  indigestion,  the 
pains  at  menstruation  disap^jear. 


CHAPTER  X. 
THE  RENAL  REFLEX  NEUROSES. 

Cases  of  marked  variations  in  the  secretion  of  urine> 
may  be  reflex  or  symptomatic.  Psychological  changes  are 
great  factors  in  modifying  the  secretion  of  the  kidneys,  the 
emotions  affecting  the  renal  secretions  even  more  strongly 
than  they  do  those  of  the  bow^els.  The  urine  secreted  under 
the  influence  of  nervous  excitement  is  copious  and  limpid. 
Sudden  changes  of  temperature  by  reflex  stimulation, 
cause  marked  renal  irritability  and  increased  micturition. 
The  hypersecretion  of  any  gland  is  simply  the  result  of  in- 
creased nerve  stimulation,  and  mental  excitement  follow- 
ing stimulation  of  the  emotions  is  a  common  cause,  not 
only  in  man  but  in  animals,  of  an  increase  in  the  secre- 
tion of  urine. 

Neuralgic  pains  are  not  so  common  in  the  kidneys  as  in: 
other  organs  of  the  body,  but  when  they  do  occur  they 
are  sometimes  very  severe  and  of  an  aching  character. 
Anything  which  tends  to  enfeeble  the  vital  powers  pro- 
duces a  marked  modification  of  the  urinary  flow.  In  very 
many  of  these  cases  of  renal  functional  disorder  there  is  ai 
large  amount  of  urea  excreted,  and  the  urine  is  of  a  very 
high  specific  gravity.  In  patients  with  nervous  prostra- 
tion the  urine  is  often  very  pale  in  color.  In  the  cases  ini 
which  there  is  an  excess  of  urea  discharged  there  is  also  a 
tendency  to  the  deposit  of  oxalate-of-lime  crystals.     These 

may  be  present  in  great  numbers  and  of  large  size.     Thej'- 

106 


THE    EEXAL    EEFLEX    XEUROSES.  lOT 

are  evidence  of  debility,  and  indicate  morbid  nervous  in- 
fluences. The  increased  secretion  of  the  watery  elements 
of  the  urine  following  upon  an  hysterical  attack  is  a  com- 
mon occurrence  in  the  practice  of  all  physicians. 

The  Duchess  of  C.  is  a  very  corpulent,  neurotic  patient, 
all  of  whose  family  were  consumptive.  She  possesses  th& 
peculiarly  thin,  silky  hair  which  accompanies  that  state, 
and  is  of  a  marked  scrofulous  diathesis.  Although  an 
elderly  woman,  she  has  a  remarkably  delicate  pink  and 
white  complexion.  She  suffers  a  great  deal  from  nervous 
dyspepsia  accompanied  by  frequent  gaseous  eructations. 
She  has  had  attacks  of  pseudo-angina  pectoris.  Her  men- 
tal condition  exercises  a  most  remarkable  influence  over 
the  renal  secretion.  While  suffering  from  nervous  excite- 
ment lasting  two  days  and  following  an  accident  to  her 
carriage,  she  urinated  about  every  ten  minutes  during 
that  time,  and  passed  a  very  large  quantity  of  pale  urine. 
She  claims  that  while  riding  either  in  a  carriage  or  in  the 
cars  anuria  exists ;  she  never  feels  the  slightest  desire  to 
urinate  even  though  the  journey  should  last  for  two  or 
three  days,  although  when  at  home  she  urinates  fre- 
quently. While  in  attendance  at  the  deathbed  of  her 
daughter  she  had  an  attack  of  polyuria  and  claims  to  have 
passed  within  a  few  hours  more  than  three  gallons.  This 
statement,  however,  may  be  taken  cum  grano  salis,  as 
a  great  many  of  these  patients  have  a  tendency  to  "  elabo- 
rate," and  possibly  she  exaggerated  a  little.  But  there  is 
no  doubt  that  she  passed  a  very  considerable  quantity. 

(Some  of  the  recent  authors  have  called  attention  to  the 
fact  that  the  granular  kidney  is  frequently  of  nervous 
origin.     See  2Iedical  Eecord,  November  Sith,  1894.) 


CHAPTER  XI. 
THE  VESICAL  REFLEX  NEUROSES. 

These  are  common  in  women,  but  the  literature  is  not 
very  extensive.  The  most  common  cause  is  some  diges- 
tive, uterine,  or  rectal  disease  affecting  the  bladder  reflexly 
through  the  sympathetic.  Lesions  of  the  cervix  are  com> 
mon  sources  of  irritation,  as  are  thread-worms,  anal  fis- 
sure, hemorrhoids,  constipation,  sudden  change  of  tem- 
perature, mental  disturbances,  and  the  irritations  of  the 
female  urethra  from  too  acid  urine,  the  result  of  bad 
digestion  or  a  urethral  caruncle. 

No  one  has  written  more  lucidly  on  this  subject  than 
Dr.  Alexander  J.  C.  Skene. 

Among  the  functional  disturbances  of  the  bladder  are 
frequent  urination,  painful  urination,  incontinence  of 
urine,  difficult  urination,  pain  after  urination,  and  reten- 
tion of  urine.  Emotional  disturbances  are  prominent  fac- 
tors in  functional  derangements  of  the  bladder;  fear  and 
fright  are  among  the  most  common  of  these  which  influ- 
ence discharge.  Frequent  urination,  and  the  sudden  evac- 
uation of  the  urine  with  modifications  of  its  character,  are 
common  results  from  disturbances  of  the  nervous  system. 
In  nervous  and  hysterical  conditions  the  urine  may  be 
limpid,  acid,  and  very  excessive  (polyuria).  Nervous  re- 
tention of  urine  (ischuria)  is  also  very  common.  Difficult 
and  painful  urination  are  likewise  conditions  frequently 

met  with  as  neuroses.     Incontinence  of  urine  in  children 

108 


THE    VESICAL    KEFLEX    LEUKOSES.  109 

is  often  dependent  upon  digestive  disorder,  and  disappears 
immediately  on  its  correction.  Many  derangements  of 
the  bladder  are  said  to  result  from  malaria.  This  can  be 
explained,  not  only  by  the  malarial  poison  affecting  the 
bladder  and  urethra  through  the  nervous  system,  but 
probably  by  a  mechanical  agency  at  work  in  addition  to 
the  nervous  cause  of  the  disease. 

The  congestion  of  the  liver  which  is  present  in  malaria 
interferes  with  the  portal  circulation  and  thus  causes  a 
congestion  of  the  bladder.  Removal  of  the  hepatic  ob' 
struction  causes  a  ready  disappearance  of  the  disorder. 
It  is  claimed  that  the  much-maligned  ovaries  are  respon^ 
sible  for  many  of  the  neurotic  disturbances  of  the  bladder. 
Ovarian  irritation  is  undoubtedly  a  frequent  factor  in  the 
production  of  excessive  urination  and  also  of  scanty  urina- 
tion and  dysuria.  ,A  feeling  of  pressure  and  uneasiness 
is  often  present;  the  pain  in  the  bladder  is  usually  con- 
fined to  the  neck,  and  is  generally  most  severe  during 
the  act  of  micturition.  In  these  cases  a  careful  examina- 
tion of  the  urine  fails  to  find  any  deviation  from  the  nor- 
mal standard.  The  bladder  itself  is  not  sensitive,  and  the 
condition  is  readily  determined  to  be  a  pure  neurosis  de- 
pendent upon  the  inflammation  and  disturbance  in  the 
ovar}'.  Treatment  directed  to  the  inflamed  ovary  usually 
causes  a  disappearance  of  the  bladder  symptoms.  It  is 
difficult  to  differentiate  between  renal  and  vesical  neuroses 
on  account  of  the  intimate  connection  of  the  parts. 

In  the  treatment  of  the  reflex  neuroses  of  the  bladder 
tonics  should  be  administered  and  a  careful  regimen  en- 
joined. Among  the  drugs  found  useful  are  nux  vomica, 
iron,  quinine,  and  the  vegetable  bitters.  The  digestive 
organs  should  receive  special  attention,  and  the  slightest 
deviation  from  their  normal  condition  should  be  at  once 


110  FUNCTIONAL   NERVOUS    DISOEDERS. 

corrected.  The  diet  should  be  simple  and  nourishing,  and 
all  indigestible  articles  carefully  excluded.  Pleasant  com- 
pany should  be  sought  after,  especially  at  meal-times,  and 
cheerfulness  should  be  cultivated.  Strong  tea  and  coffee, 
wines,  condiments,  and  all  other  articles  which  are  inhibi- 
tory of  digestion  should  be  strictly  avoided.  Diluents  and 
soothing  decoctions  should  be  given  by  the  mouth.  The 
mild  alkalo-saline  waters,  such  as  Highland  water,  and 
preparations  of  uva  ursi,  triticum  repens,  scoparium,  and 
acacia  are  useful  for  removing  irritation.  Local  applica- 
tions of  laudanum,  belladonna,  chloral,  and  morphine 
may  be  used  with  advantage  either  as  suppositories  or  in- 
jections per  rectum.  Bladder  injections  containing  a 
small  quantity  of  morphine  are  also  useful  in  removing  the 
sensitiveness  of  the  mucous  membrane. 

Enuresis  is  a  common  and  troublesome  affection  of 
childhood,  often  difl&cult  to  manage.  It  is  most  common 
in  nervous  children  suffering  with  digestive  disorders. 
It  is  undoubtedly  in  many  cases  a  neurosis  resulting  from 
reflex  irritation.  The  various  causes  of  this  disorder  are 
obscure.  The  most  valuable  remedies  are  those  which  are 
tonic  in  their  action,  such  as  iron  and  strychnine.  Tinc- 
ture of  belladonna  is  recommended  in  five-drop  doses. 

The  whole  subject  of  reflex  bladder  troubles  is  a  vexed 
question,  and  these  disorders  are  often  difficult  of  diagno- 
sis. A  most  thorough  investigation  to  discover  the  cause 
of  the  trouble  should  be  made  before  any  course  of  treat- 
ment is  attempted. 

My  friend.  Dr.  R.,  gives  me  the  details  of  the  following 
case : 

Mrs.  H.  had  been  married  for  about  four  months,  and 
the  marriage  had  never  been  properly  consummated  owing 


THE   VESICAL    REFLEX    NEUEOSES.  Ill 

to  the  fact  that  the  approach  of  her  husband  had  always 
resulted  in  a  sudden  and  uncontrollable  emptjang  of  her 
bladder,  a  real  incontinence  of  urine.  It  had  never  oc- 
curred before  she  was  married,  and  never  at  any  other 
time  than  on  attempting  to  perform  the  marital  act.  No 
matter  how  often  or  how  infrequently  the  attempts  were 
made,  the  result  was  always  the  same.  The  consequence 
was  that  the  husband  was  thoroughly  disgusted  and  unable 
to  accomplish  the  act.  Strychnine,  belladonna,  and  can- 
nabis indica  were  tried  without  any  benefit.  Cauteriza- 
tion of  the  neck  of  the  bladder,  however,  was  followed  by 
marked  improvement. 


CHAPTER   XII. 
THE  REFLEX  GENITAL  OR  HYSTERO-NEUROSES. 

Many  of  the  hj^stero-neuroses  are  very  severe  in  their 
manifestation.  They  most  commonly  occur  at  the  men- 
strual period.  Genito-urinary  disturbances  are  reflected 
to  any  part  of  the  body,  but  more  frequently  to  the  hypo- 
gastrium,  the  vertex,  and  the  occiput.  Pains  are  also  fre- 
quent in  the  lumbar  region,  knees,  ankles,  and  wrists;  also 
in  the  neck  below  the  occiput.  The  terminals  of  the  cere- 
bro-spinal  nerves  are  frequently  implicated. 

When  hystero-neuroses  are  constant,  they  are  usually 
increased  in  severity  by  menstruation,  or  by  anything 
which  causes  uterine  congestion,  such  as  colds  or  over- 
exertion. Sometimes,  however,  the  menstrual  discharge 
decreases  their  severity.  The  pains  in  the  small  of  the 
back  follow  the  distribution  of  the  nerves  around  to  the 
h5^pogastric  region,  and  the  pain  is  usually  more  marked 
on  the  diseased  side.  It  is  sometimes  localized  between 
the  shoulder-blades.  I  had  a  patient  in  whom  the  pains 
of  labor  were  all  reflected  to  the  head.  She  was  also  a 
victim  of  hystero-epilepsy.  Another  patient  had  them  all 
in  the  thighs — this  latter  is  a  rather  common  condition. 

The  pains  of  the  hypogastric  neuroses  are  superficial, 
and  are  diffused  along  the  terminal  nerves;  while  the 
pain  from  local  inflammator}^  conditions  is  deep-seated, 
and  due  to  direct  mechanical  pressure. 

The  pain  in  the  occiput  and  back  of  the  neck  is  com- 

112 


THE   HYSTERO-NEUROSES.  113 

monly  described  by  the  patient  as  being  "  like  two  drawn 
cords  in  the  nape  of  the  neck." 

In  the  vertex  the  pain  is  commonly  of  a  pressing  or 
burning  character,  and  an  eruption  or  dermatosis  some- 
times results. 

A  very  common  hystero-neurosis  is  the  quiverings  and 
shakings  in  the  abdomen,  of  which  a  large  number  of 
patients  complain. 

Superficial  pains  in  the  toes,  soles  of  the  feet,  and  heels 
are  often  said  to  result  from  ovarian  and  uterine,  as  well 
as  from  gastric  disease.  They  usually  occur  on  the  same 
side  as  that  of  the  affected  tube  or  ovary,  and  in  gastric 
disease,  if  the  left  side  be  painful,  then  the  greater  cur- 
vature of  the  stomach  is  the  probable  seat  of  the  inflamma- 
tion. If  the  toes  and  fingers  of  the  right  side  are  affected, 
then  without  doubt  a  duodenitis  is  the  cause,  the  irritation 
being  at  the  pyloric  orifice  of  the  stomach.  This  is  due 
probably  to  the  distribution  of  the  sympathetic  nervous 
system. 

Coccygodynia  is  sometimes  a  hystero-neurosis. 

Narcolepsy,  Trance,  Lethargy,  Hallucinations,  Ante- 
cedent to  the  Establishment  of  the  Menstrual  Function 
{a  Hystero-Neurosis) . — Edna  S,,  aged  12,  still  in  short 
dresses,  is  in  good  condition  physically ;  suffers  with  head- 
ache, mostly  frontal,  more  frequent  in  the  afternoon  ;  is  a 
thoughtful,  energetic,  bright,  cheerful  child,  with  an  ex- 
ceedingly acute  memory.  She  has  the  face  of  a  girl  of 
sixteen.  Appetite  good ;  bowels  regular ;  is  not  anaemic, 
and  has  a  plentiful  supply  of  fresh  air.  Her  mother  died 
of  phthisis  when  the  child  was  five  years  old;  her  father 
is  ver}^  frail  and  delicate.  On  returning  from  school,  for 
some  time  past,  she  has  always  been  dizzy  and  drowsy  and 
wishes  to  go  to  bed  immediately,  instead  of,  as  heretofore, 
playing  with   her  dolls  and   enjoying   herself.     After   a 


114  FUNCTIONAL    NERVOUS    DISORDERS. 

quarrel  or  an  attack  of  fretting,  she  has  hysterical  hallu- 
cinations of  vision,  every  object  seeming  of  double  size. 
Every  object  that  comes  in  contact  with  her  body,  such  as 
a  sheet,  seems  to  be  extremely  heavy.  When  in  a  nervous 
state  after  crying,  she  has  the  feeling  that  the  lips,  tongue, 
and  hands  are  swollen  to  a  great  size,  although  no  swelling 
is  visible.  She  usually  retires  between  8  and  9  p.m.  In 
the  morning  when  awakened  and  called  to  get  up,  she 
hears  but  cannot  move;  her  mind  is  awake  but  she  has  no 
power  of  motion ;  her  eyelids  are  closed  and  she  has  to  be 
vigorously  shaken  everj^  morning.  She  is  not  lazy  or  tired, 
but  she  cannot  move  a  muscle  when  in  this  state.  She 
will  hear  commands  and  orders,  but  is  unable  to  obey 
them,  and  lies  like  a  log.  If  left  alone,  she  will  remain  in 
this  condition  for  from  twelve  to  fifteen  hours.  At  times 
there  is  a  sensation  of  constriction,  as  of  a  band  around 
the  head. 

Her  father  has  suffered  from  attacks  of  trance.  He 
has  lain  in  a  cataleptoid  state,  heard  and  knew  his  friends 
by  their  voices,  but  has  been  unable  to  move — mind 
awake,  but  body  asleep. 

When  sensation  is  returning,  in  the  case  of  the  child,  a 
peculiar  prickling,  as  of  needles,  is  felt  in  an  increased  de- 
gree. After  coming  out  of  an  attack  she  often  has  to  slap 
her  hands  to  aid  the  return  of  sensation. 

Under  treatment  by  tonics  and  a  nutritious  diet  this 
patient  has  very  much  improved. 

I  wish  to  refer  here  to  a  pathological  condition  which  I 
have  observed,  and  which  has  not  yet  (to  my  knowledge) 
been  noted  save  by  a  very  few  medical  authors.  I  refer 
to  recurrent  sexual  orgasms  in  women.  In  the  following 
cases  they  existed  as  a  reflex  from  ovarian  irritation : 

Mrs.  S.,  aged  22,  very  ansemic;  has  had  two  children,  no 
miscarriages;  last  pregnancy  four  months  ago;  did  not 
nurse  the  baby,  and  it  died  from  marasmus.  Has  been 
weak  and  nervous  for  the  last  five  years.     Has  had  within 


THE   HYSTERO-XEUROSES.  115 

a  short  time  four  attacks  of  sexual  orgasm,  with  consider- 
able discharge.  Bowels  constipated.  Has  pain  in  the  left 
ovarian  region. 

Miss  C.  H.,  aged  27,  pale,  large,  strongly  built.  Has  an 
orgasm  three  or  four  times  some  days.  Uterus  tender  on 
examination.  Has  a  burning  sensation  in  left  ovarian 
region. 

Mrs.  A.  R.,  aged  36,  widow.  Married  twelve  years; 
widow  for  nine  j^ears ;  three  children.  Menses  first  at  1-i ; 
they  recur  every  two  or  three  weeks,  duration  five  to 
eight  days,  flow  profuse.  Has  some  aching  pain  twenty- 
four  hours  before  the  flow  and  continuing  through  the  first 
day.  Leucorrhoea,  slight  but  continuous.  With  the  bear- 
ing-down pains  has  an  orgasm.  Does  not  masturbate  or 
have  connection ;  very  sensitive  about  the  internal  genitals. 
Urinates  every  fifteen  or  twenty  minutes.  Bowels  regular. 
Has  lacerated  cervix. 

Rosenthal,  of  A^ienna,  says: 

"  I  had  under  ray  care  a  young  hysterical  female  who 
performed  peculiar  suction  movements  during  her  parox- 
ysms, during  sleep,  and  in  a  condition  of  semi-conscious- 
ness. One  day,  as  her  consciousness  was  returning,  I  dis- 
covered a  mucous  fluid  upon  the  external  genitals,  al- 
though the  genital  organs  were  normal.  After  having 
often  observed  a  similar  occurrence,  I  decided  to  warn  the 
patient  that  she  was  concealing  secrets  from  me  which 
would  undoubtedly  result  to  her  detriment.  She  then  con- 
fessed that  she  secretly  read  light  novels  at  night,  that  she 
then  had  erotic  dreams,  and,  that  upon  waking,'  she  felt 
exhausted  and  worn  out.  The  hysterical  paroxysms  de- 
veloped after  this  condition  of  excitement  had  lasted 
several  months.  A  trip  to  the  country  and  hydrothera- 
peutic  measures  caused  the  disappearance  of  the  pollutions, 
and  the  hysterical  seizures  yielded  soon  afterward.  In 
another  case,  a  patient,  during  profound  sleep,   saw  her 


116  FUNCTION"AL   NEEVOUS   DISORDERS. 

dead  mother  appear  before  her,  and  begged  her  pardon  for 
concealing  the  fact  that  she  had  a  mucous  discharge  from 
the  genitals  after  voluptuous  dreams,  blaming  the  obscene 
books  loaned  by  a  friend  as  the  cause  of  the  discharge 
and  of  the  hysterical  paroxysms.  This  flux,  caused  by 
erotic  excitement  of  the  nervous  system,  is  produced  by  the 
glands  of  Bartholin  and  by  the  acinous  glands  surround- 
ing the  meatus  urinarius." 

As  a  rule  these  involuntary  orgasms  occur  at  night  and 
result  from  masturbation,  erotic  thoughts,  and  over-ex- 
citement of  the  genital  organs  by  stimulating  food  and 
drinks,  diseases  of  the  rectum,  hemorrhoids,  habitual 
constipation,  and  worms ;  diseases  of  the  bladder,  inflam- 
mation and  calculi,  irritation  of  the  urethra  and  glans 
clitoridis.  These  orgasms  weaken  the  nervous  system  and 
lower  the  vital  energies,  thus  affecting  nutrition.  When 
long  continued  they  cause  melancholia  and  mental  weak- 
ness. 

In  the  treatment  of  these  conditions,  as  in  that  of  all  the 
reflex  neuroses,  we  should  endeavor  to  remove  the  cause. 
When  they  are  due  to  constipation  or  hemorrhoids,  these 
should  be  relieved  by  attention  to  the  liver  and  digestive 
tract.  If  worms  are  present,  we  should  give  injections  of 
the  cold-water  infusions  of  quassia,  or  very  weak  solutions 
of  carbolic  acid,  corrosive  sublimate  or  vinegar,  the  latter 
being  preferable  on  account  of  its  less  poisonous  action. 
It  is  also  very  important  when  these  parasites  are  present 
to  abstain  for  a  time  from  the  use  of  sweets  and  fresh  milk, 
and  to  add  much  salt  to  the  diet. 

These  patients  should  sleep  on  a  hard  mattress,  lying 
upon  the  side  and  with  merely  a  light  covering.  The  dorsal 
decubitus  tends  to  stimulation  of  the  genital  organs. 

Among  the  drugs  which  may  be  administered  are  qui- 


THE   HYSTEEO-XEUROSES.  117 

uine  and  iron  for  their  tonic  effect,  and  Fowler's  solution, 
belladonna,  camphor,  lupulin,  and  bromide  of  potassium. 
From  these  good  results  may  be  expected.  Great  benefit 
is  also  derived  from  cold  sponging  of  the  body.  Electric- 
ity is  also  useful,  but  its  application  should  not  be  too 
severe  or  prolonged. 


CHAPTER  XIII. 

THE    GLANDULAR    REFLEX    NEUROSES. 

Probably  the  most  important  glands  which  we  have  to 
consider  in  this  connection  are  the  breasts.  All  irrita- 
tions in  the  pelvic  organs  manifest  themselves  to  a  greater 
or  less  degree  by  changes  in  the  mammary  glands.  The 
most  common  reflexes  are  swelling,  engorgement,  and 
pain.  These  glands  are  intimately  connected  with  the 
other  sexual  organs,  and  the  functional  activity  of  both  is 
absolutely  interdependent  as  they  are  but  different  parts  of 
one  apparatus — the  sexual. 

Sensations  of  tenderness  in  the  mamma  are  not  infre- 
quent manifestations  in  young  women  at  their  menstrual 
periods,  and  at  the  beginning  of  pregnancy.  Again,  at 
the  period  of  the  "  climacteric  "  sensations  of  similar  nat- 
ure may  occur  and  they  may  accompany  various  diseased 
conditions  of  the  pelvic  organs.  The  subjects  usualty 
affected  are  women  of  a  highly  sensitive  disposition  or 
those  with  hysterical  tendencies.  The  tenderness  may  be 
very  slight,  or  there  may  be  actual  and  severe  pain. 
Sometimes  so  excessive  is  the  tenderness  that  the  slight- 
est touch  cannot  be  endured.  When  this  is  the  case  it  is 
termed  mastodynia.  Many  patients  afflicted  with  mas- 
todj'nia  are  thoroughly  convinced  that  they  are  suffering 
from  cancer  or  some  other  serious  ailment.  Tonic  treat- 
ment, with   local   sedatives   and   dietetic  regulation,  are 

often  the  only  remedial  measures  necessary. 

118 


THE    GLANDULAE    REFLEX    NEUROSES.  119 

Uterine  or  ovarian  pain  resulting  from  inflammation  is 
frequently  accompanied  by  a  reflex  pain  in  the  breast,  and 
disturbances  of  the  uterine  condition,  either  by  menstrua- 
tion or  conception,  are  usually  followed  by  congestion 
of  the  mammary  glands.  In  some  cases  of  dysmenor- 
rhoea  the  breasts  become  exceedingly  tense  and  painful. 
The  pain  is  of  a  lancinating  character,  penetrating  to  the 
shoulder  blades,  and  is  present  during  the  entire  menstrual 
period,  but  disappears  upon  the  cessation  of  the  flow.  In 
other  cases  the  shooting  pains  in  the  breast  and  the  sore- 
ness of  the  nipples  precede  the  appearance  of  the  menstrual 
discharge,  and  pass  away  entirely  with  its  disappearance. 

Changes  in  the  other  glands,  accompanying  pathological 
conditions  of  the  digestive  organs,  are  much  more  common 
than  is  generally  supposed  and  have  not  to  any  very  great 
extent  been  brought  to  the  attention  of  the  medical  pro- 
fession. 

Thyroid  enlargement  is  often  a  well-known  reflex,  de- 
pending upon  activity  of  the  genital  organs  in  the  female. 
This  was  well  known  by  the  ancients,  who  considered  en- 
largement of  the  neck  as  an  evidence  of  consummation  of 
marriage  or  of  the  occurrence  of  pregnancy.  It  was  cus- 
tomary to  measure  the  neck  with  a  fillet  before  and  after 
the  first  night  of  the  married  state.  I  am  inclined  to 
think  that  the  globus  hystericus  is  nothing  more  nor  less 
than  a  neurosis  dependent  upon  the  physiological  conges- 
tion of  the  thyroid. 

H^'^persecretion  of  the  salivary  glands  i|^  frequently 
known  to  accompany  menstruation,  and  is  one  of  the  first 
signs  of  pregnancy.  It  is  sometimes  very  severe  and 
annoying  in  the  early  months,  and  does  not  entirely  pass 
away  until  delivery.  There  is  an  intimate  connection  be- 
tween the  parotid  glands  and  the  reproductive  organs. 


120  FU2<rCTI0]S"AL   NERYOUS    DISORDERS. 

Cases  have  been  reported  where  a  diseased  ovary  has 
caused  reflexly  the  suppression  of  the  secretion  of  the 
parotid  gland  on  the  same  side.  Parotiditis  sometimes 
causes  a  painful  oophoritis.  This  is  undoubted^  due  to 
sympathetic  transference,  such  as  takes  place  in  the  testes 
of  the  male.  SeA^ere  inflammation  of  the  parotid  has  taken 
place  in  cases  of  ovariotom}'.  Several  instances  of  this 
kind  have  been  reported  by  Drs.  Emmet,  Mann,  Reamy, 
and  others. 

Hepatic  neuroses  are  frequently  dependent  upon  emo- 
tional disturbances.  This  fact  is  well  known  to  non-medi- 
cal writers,  for  the  novelists  speak  of  the  sallow  counte- 
nance presented  by  the  hero  or  villain  after  he  has  passed 
a  sleepless  night,  torn  by  conflicting  emotions.  The  emo- 
tional jaundice  is  here  probably  the  result  of  disturbances 
of  the  vasomotor  system. 

Many  of  the  glandular  neuroses  have  been  considered 
under  other  headings,  such  as  intestinal,  renal,  etc. 

Excessive  perspiration  of  the  hands  and  feet,  as  a  reflex 
symptom  from  digestive  disorder,  is  very  common.  The 
feet  in  these  patients,  being  encased  in  shoes  which  pre- 
vent evaporation,  often  present  the  white  and  wrinkled 
appearance  seen  when  the  skin  has  been  soaked  for  a  long 
period  in  a  strong  solution  of  soda. 

Many  persons  with  weakened  digestive  organs  and  con- 
stipation have  a  strong  odor  in  the  urine,  due  to  intestinal 
decomposition  of  sulphur  compounds  and  the  pronounced 
appearance  of  indican  in  the  excretion.  It  is  probably  the 
same  decomposition  that  produces  the  malodorous  perspi- 
ration in  the  axilla,  and  which  is  often  much  more  exces- 
sive on  the  right  side.  Its  greater  frequency  there  is 
probably  due  to  the  presence  of  the  liver  and  the  empty- 
ing of  the  portal  S3"stem  on  that  side.     In  some  of  these 


THE    GLANDULAR   REFLEX   N"EUROSES.  121 

subjects  the  left  axilla  may  be  entirely  free  from  odor. 
This  odor  is  of  a  much  stronger  kind  in  the  negro  race, 
and  also  in  people  with  very  pronounced  red  hair.  Some 
young  women  of  the  latter  type  suffer  much  from  this 
pecularitj'.  In  the  ball-room,  when  they  become  heated 
from  dancing  and  are  perspiring  profusely,  it  requires  the 
whole  effect  of  the  very  powerful  and  pungent  perfumes 
which  they  use  to  disguise  this  disagreeable  odor. 

Hyperhidrosis — Ephidrosis. — The  following  case  lately 
came  under  my  notice,  but  circumstances  prevented  me 
from  making  more  than  a  superficial  examination : 

Mr.  H.,  a  young  man,  a  blond,  25  years  of  age,  much 
addicted  to  the  use  of  alcohol,  exhibits  a  curious  phase 
of  this  condition.  On  the  warmest  days,  and  after  vio- 
lent exercise,  he  will  exhibit  no  signs  of  perspiration  on 
his  head,  face,  or  neck,  but  from  the  second  joints  to  the 
extremities  of  the  fingers  of  each  hand  a  copious  perspira- 
tion will  be  present.  So  profuse  is  it  that  he  can  by  shak- 
ing his  hand  sprinkle  the  perspiration  around  in  large 
drops.  This  peculiar  condition  may  be  the  result  of  some 
morbid  process  in  the  liver,  such  as  diabetes. 

The  glandular  organs  of  the  body  are  markedly  influ- 
enced by  the  vasomotor  irritations  arising  in  the  sympa- 
thetic. The  glycogenic  function  of  the  liver  and  excretion 
by  the  kidneys  are  under  the  control  of  the  sympathetic. 

The  cervical  sympathetic,  as  well  as  its  distribution  in 
the  thorax  may,  when  irritated  and  disturbed,  cause  uni- 
lateral hypersecretion  of  sweat.  Cases  have  been  reported 
of  unilateral  hyperhidrosis  the  result  of  Basedow's  disease 
or  diabetes.  Here  there  is  myosis  on  the  affected  side, 
redness  of  the  skin,  and  elevation  of  temperature.  In  one 
of  these  cases  galvanization  of  the  cervical  sympathetic 
caused  profuse  sweating  upon  the  corresponding  part  of 
the  face  and  head,  while  in  another  case  a  result  exactly 


122  FUNCTIONAL   NEEVOrS    DISOEDERS. 

opposite  was  obtained.  Fraenkel,  in  his  Inaugural  Dis- 
sertation, Breslau,  1874,  reports  the  case  of  a  patient 
with  cardiac  and  thyroid  hypertrophy,  accompanied  by 
attacks  of  dyspnoea  and  hyperhidrosis  of  the  left  half  of 
the  face.  On  autopsy  the  left  cervical  sympathetic  was 
found  covered  with  rounded  nodules  as  large  as  grains  of 
sand,  blackish-brown  in  color.  On  microscopic  examina- 
tion they  were  found  to  consist  of  varicose  vascular  dila- 
tations with  a  formation  of  fusiform  cells  in  their  walls. 
The  ganglion  cells  were  strongly  pigmented  and  filled  with 
dark  cells. 

Seguin,  in  the  American  Journal  of  the  Medical  Sci- 
ences, October,  1872,  reported  a  case  of  a  male  patient,  aged 
fifty  years,  who  came  under  his  notice.  This  man  had 
exhibited  for  a  number  of  years  a  imilateral  hyperhidrosis 
in  which,  while  the  left  side  was  profusely  bathed  in  per- 
spiration, the  right  remained  entirely  dry.  The  patient 
died  of  exhaustion,  and  the  autopsy  revealed  large  cancer- 
ous masses  in  the  abdominal  cavity  affecting  principally 
the  mesenteric  glands.  Another  deposit  of  carcinomatous 
tissue  as  large  as  a  small  orange  was  found  behind  the 
left  clavicle,  external  to  the  sterno-mastoid  muscle.  On 
the  right  side  the  cervical  sympathetic  was  found  to  be 
adherent  to  the  sheaths  of  the  pneumogastric  nerve  and 
the  vessels.  The  superior  ganglion  and  adjacent  parts 
were  much  injected. 

These  conditions  are  certainly  of  much  interest.  In  some 
cases  mechanical  compression  of  the  sympathetic  nerve 
is  readily  determined,  while  in  others  the  condition  is 
quite  probably  of  reflex  origin,  from  disturbance  in  the 
thoracic,  abdominal,  or  pelvic  cavities. 

Hemidrosis — Unilateral  Hyperhidrosis. — This  is  not 
a  very  unusual  condition.     In  two  cases  which  recently 


THE    GLAXDULAR    REFLEX    XEUROSES. 


123 


came  under  my  observation  the  left  side  was  affected. 
One  was  a  lady  of  about  thirty,  of  strong  frame,  but  suf- 
fering at  this  time  from  a  severe  chronic  bronchitis,  worse 
on  the  left  side.  The  explanation  of  the  hemidrosis  in  this 
case  would  seem  to  be  that  the  ganglia  of  the  sympathetic 
in  the  region  of  the  left  lung  were  excited,  and  the  fibres 


Fig.  10. —Hemidrosis. 

also  of  the  sympathetic  controlling  the  secretion  of  sweat 
were  stimulated  by  a  local  sepsis;  or,  the  pressure  of  the 
enlarged  bronchial  glands  caused  the  stimulation,  and  took 
this  means  (unilateral  sweating)  of  ridding  the  body  of 
the  poison.  Half  of  the  face,  head,  and  body  were  bathed 
in  a  profuse  perspiration,  the  hair  on  that  side  being  very 


124  FUNCTIONAL   NEEVOUS    DISOEDEES. 

wet,  while  the  opposite  side  of  the  face,  head,  and  body 
was  perfectly  dry.  In  the  other  case  the  cause  of  the  func- 
tional aberration  was  not  determined,  the  patient  being 
apparently  in  robust  health.  She  passed  from  my  observa- 
tion before  the  obscure  cause  of  the  disorder  could  be 
ascertained. 

The  pathology  of  this  symptom  is  obscure.  It  is  well 
known  that  severance  of  the  sympathetic  in  horses  causes 
a  profuse  unilateral  perspiration. 

A  case  is  reported  of  paroxysms  of  angina  pectoris  with 
hyperhidrosis  of  the  left  side.  On  post-mortem  examina- 
tion the  ganglia  of  the  left  sympathetic  showed  a  patho- 
logical condition  of  the  blood-vessels,  which  were  dilated 
and  varicose,  while  the  nerve  tissue  on  the  right  side  was 
perfectly  normal.  In  this  case,  Ebstein  claimed  that  the 
hyperhidrosis  resulted  from  a  temporary  or  j)ermanent 
compression  of  the  nerve  elements  of  the  sympathetic  with 
resulting  paralysis.  Rockwell  reports  a  case  which  indi- 
cates an  involvement  of  the  vasomotor  and  oculo-pupillary 
fibres  of  the  sympathetic. 

Patient,  a  male,  set.  65,  was  extremely  feeble,  and 
suffering  from  digestive  disorders.  There  was  profuse 
unilateral  hyperhidrosis  involving  the  right  side  of  the 
body,  and  the  right  leg  and  foot  to  a  less  extent,  while  the 
left  side  was  at  all  times  abnormally  dry,  the  median  line, 
both  front  and  back,  sharply  defining  the  two  conditions. 
There  was  persistent  congestion  of  the  conjunctivae.  The 
right  ear  was  redder  and  hotter  than  the  left.  There  was 
considerable  myosis,  suggestive  of  paralysis  of  the  oculo- 
pupillary  as  well  as  sympathetic  vasomotor  fibres.  The 
hyperhidrosis  lessened  under  the  galvanic  and  faradic 
currents. 

Localized   perspiration    is   much   more    common    than 


THE    GLANDULAR    REFLEX    NEUROSES.  125 

general  perspiration.  In  some  cases  it  is  confined  to  the 
hands  and  feet  alone;  in  others  the  axillae,  scalp,  and  peri- 
neum are  the  only  parts  affected.  I  have  at  present  under 
my  observation  a  brother  and  sister,  both  of  whom  sweat 
excessively  from  the  hands  and  feet.  In  the  case  of  the 
young  man,  who  is  about  eighteen,  the  feet  are  the  most 
affected.  They  are  constantly  soaked  with  perspiration, 
and  have  the  peculiar  wrinkled  appearance  presented  by 
the  hands  of  a  washerwoman  who  has  been  all  day  engaged 
at  her  avocation.  In  these  two  cases,  as  with  most  patients 
suffering  from  this  disorder,  both  diet  and  hygiene  are 
improper.  A  strong  solution  of  chromic  acid,  as  a  local 
application,  was  of  benefit  to  both  of  these  patients. 

Hartmann  mentions  the  case  of  a  woman  who  during 
pregnancy  perspired  only  from  the  right  side  of  the  body, 
and  Sir  Erasmus  Wilson  speaks  of  a  young  lady  under  his 
care  whose  hands  drip  with  perspiration,  the  palms  filling 
with  the  secretion,  under  the  influence  of  a  slight  ner- 
vous excitement.  He  also  mentions  the  case  of  a  man  with 
severe  gastric  disorder  who  called  on  him  one  morning 
with  "  rills"  of  perspiration  running  down  one  side  of  his 
face  and  forehead,  the  other  side  being  perfectly  dry. 

An  eminent  actor  told  him  the  following  anecdote  of 
himself.  When  a  young  man  he  had  one  night  been 
playing  in  a  tragedy  in  which  he  had  become  violently 
heated,  and  had  scarcely  had  time  to  cool  when  he  had 
been  obliged  to  go  on  the  stage  again  in  a  character  which 
required  that  he  should  make  up  as  an  old  man  of  eighty. 
In  the  course  of  the  play  he  had  been  struck  by  the  great 
amount  of  attention  of  which  he  was  the  recipient,  especial- 
\y  from  those  in  the  audience  who  were  nearest  to  the  stage. 
Concluding  that  it  was  the  excellence  of  his  acting  which 
was  attracting  such  attention,  he  felt  flattered  and  exerted 


126  FUl^CTIOlSrAL   ]S'ERYOrS    DISOEDEES. 

himself  to  the  utmost.  He  was  thoroughly  puzzled,  how- 
ever, at  the  sensation  which  he  seemed  to  be  creating,  and 
at  the  bursts  of  laughter  in  the  wrong  places  which  greeted 
him.  Upon  retiring  to  his  dressing-room  he  found  that  it 
was  not  alone  the  excellence  of  his  acting  which  had  so 
excited  his  audience,  but  the  droll  appearance  of  his  face, 
one-half  of  which  had  been  washed  clear  of  its  painted 
wrinkles  by  a  partial  perspiration  and  displayed  the  youth- 
ful features  of  a  young  man  of  twenty,  while  the  other  half 
exhibited  the  careworn  lines  and  wrinkles  of  eighty. 

On  his  chest  the  perspiratory  side  was  reversed,  the 
side  corresponding  to  the  perspiring  side  of  the  face  being 
perfectly  dry,  and  the  other  side  bathed  in  a  profuse  sweat. 
At  a  later  period  the  perspiratory  action  ceased  over  the 
entire  body. 

Cutaneous  hemidrosis  may  be  considered  as  a  neurosis 
referable  to  the  cutaneous  system.  I  prefer  not  to  class  it 
as  a  dermatosis. 

Bromidrosis. — My  friend,  Dr.  Peter  Murray,  has  given 
me  the  particulars  of  the  following  case  of  bromidrosis : 

Miss  G.,  aged  18  years,  suffered  for  a  considerable'  time 
with  excessive  and  most  fetid  perspiration  of  the  feet,  and 
so  copious  was  the  secretion  that  as  she  walked  across  the 
floor  a  "swashing"  sound  was  heard  at  every  step,  her 
shoes  being  literally  full  of  water.  The  special  point  of 
interest  is  the  immediate  success  of  the  treatment  insti- 
tuted. The  feet  were  bathed  in  hot  water,  and  afterward 
liberally  powdered  with  a  mixture  of  equal  parts  of  sali- 
cylic acid  and  borax.  This  caused  considerable  irritation 
for  two  days.  Extract  of  witch-hazel  was  also  used  after 
the  hot  water  with  the  result  of  completely  curing  the  dis- 
order. The  patient  was  seen  a  year  afterward,  and  had 
had  no  relapse. 

Dr.   Murray    also  mentioned   the  case  of  a  gentleman 


THE    CtLAXDULAR    REFLEX    NEUROSES.  127 

with  whom  he  is  acquainted  who  claims  never  to  have 
perspired.  Upon  the  hottest  days  his  face  gets  intensely 
red  and  shiny,  and  appears  as  if  about  to  burst,  but  re- 
mains perfectly  dry.  The  patient's  age  is  sixty-five,  and 
he  is  of  a  thin,  spare  habit. 

I  remember  some  years  since  having  seen  a  lady  of 
about  fifty  years  who  suffered  in  a  precisely  similar  man- 
ner, never  perspiring  even  in  the  hottest  weather  or  after 
severe  muscular  exertion;  she  had  some  eczema  of  the 
upper  extremities,  and  was  almost  bald.  The  suppression 
of  the  sweat  secretion  was  productive  of  considerable  ex- 
haustion and  much  distress. 

A  saturated  solution  of  bichromate  of  potash,  applied 
twice  a  day,  is  said  to  be  a  sure  cure  for  bromidrosis.  It 
ivas  of  advantage  in  all  the  cases  in  which  I  have  used  it. 
In  the  German  army  dilute  chromic  acid  is  said  to  be 
almost  exclusively  employed  for  excessive  sweating  of  the 
feet. 

I  have  also  prescribed  chromic  acid  with  much  success 
for  patients  who  suffer  from  this  disorder  and  who  engage 
in  avocations  requiring  the  handling  of  polished  steel  in- 
struments. On  account  of  its  acid  character  the  perspira- 
tion is  most  destructive  to  the  polish  on  such  instruments. 


CHAPTER  XIV. 
THE    OPHTHALMIC  REFLEX  NEUROSES. 

Many  ophthalmic  symptoms  are  dependent  not  only 
upon  ovarian  and  uterine  affections  but  are  common 
manifestations  of  digestive  disorder.  They  are  indepen- 
dent of  any  structural  change  in  the  eye.  Among  the 
more  common  reflex  neuroses  of  the  eye  are:  asthenopia, 
amblyopia,  hysterical  amaurosis,  menstrual  amaurosis, 
gravidarum  amaurosis,  retinal  hypersesthesia,  retinal 
ansesthesia,  photophobia,  dimness  of  vision,  mouches 
volantes,  disturbances  of  accommodation,  hysterical  stra- 
bismus, hemeralopia  (night  blindness),  nyctalopia  (day 
blindness),  mydriasis,  and  myosis. 

It  is  not  at  all  uncommon  for  patients  afflicted  with 
chronic  abdominal  and  pelvic  disease  to  be  troubled  with, 
asthenopia  and  dimness  of  vision,  yet  in  the  mind  of  the 
average  practitioner  the  interdependence  or  reflex  charac  • 
ter  of  these  conditions  is  by  no  means  well  established. 
Cases  of  transitory  amaurosis  or  amblyopia  resulting  regu- 
larly from  a  menstrual  reflex,  have  been  reported,  and. 
these  have  disappeared  completely  under  uterine  treat- 
ment. In  some  cases  the  ophthalmic  symptoms  are  cere- 
bral neuroses  or  psychoses,  being  of  hysterical  origin.  In 
many  patients  undoubtedly  the  weakness  of  the  eyes  is- 
dependent  upon  the  general  systemic  weakness  arising- 
from  chronic  digestive  disorder,  and  a  good  course  of  tonic, 

dietetic,  and  hygienic  treatment  would  invigorate  the  sys- 

128 


THE    OPHTHALMIC    REFLEX    NEUROSES.  129 

tern  sufficiently  to  cause  them  to  disappear;  yet  in  some 
instances  they  are  true  reflex  neuroses.  In  a  patient  under 
my  care  there  is  not  only  impairment  of  vision  but  there 
is  a  limitation  of  the  visual  field.  If  she  endeavors  to 
read,  or  gazes  steadily  at  any  fixed  object  for  a  time,  dark, 
wavy  lines  seem  to  intervene.  There  is  no  structural  dis- 
ease of  the  eye  present;  the  patient  is  neurasthenic,  and 
suffers  from  chronic  gastric  catarrh,  cardiac  weakness, 
and  incipient  renal  disease. 

Disturbances  of  vision  are  quite  common  as  menstrual 
neuroses  where  pelvic  inflammation  is  present,  the  greater 
involvement  being  in  that  eye  corresponding  to  the  side 
where  the  inflammation  is  the  more  intense. 

Retinal  hypersesthesia  and  anaesthesia  are  not  only  cere- 
bral neuroses  but  are  common  results  of  peh'ic  inflamma- 
tion. They  also  result  from  indigestion  following  the  use 
of  coarse  vegetable  food.  Ptosis  may  result  from  the  irri- 
tation reflected  from  hepatic  and  gastric  disease.  Lacera- 
tion of  the  cervix  is  responsible  for  some  of  the  reflex 
ophthalmic  neuroses.  It  is  claimed  that  photophobia  may 
also  result  as  a  reflex  from  endometritis  and  cellulitis. 

Puerperal  amaurosis  resulting  from  eclampsia  might  be 
classed  as  a  cerebral  neurosis  depending,  as  it  probably 
does,  on  ursemic  poisoning  of  the  cerebral  centres.  This 
functional  disorder  must  not  be  confounded  with  retinitis 
albuminurica,  from  which  it  is  entirely  distinct. 

Asthenopia  is  sometimes  a  cerebral  neurosis  dependent 
on  a  lack  of  mental  energy;  the  patient  has  lost  confi- 
dence in  his  power  of  using  his  eyes.  Psychological 
treatment  is  here,  of  course,  indicated. 

Many  cases  are  on  record  of  hysterical  amblyopia  and 

amaurosis  and  a  great  variety  of  means  have  been  adopted 

for  the  sudden  cure  of  these  cerebral  neuroses.     Persons 
9 


130  FUNCTIONAL   NERVOUS    DISORDERS, 

with  weak  eyes  should  not  read,  write,  or  do  any  fine 
sewing  on  an  empty  stomach.  A  neurasthenic  patient  of 
mine  who  suffered  greatly  from  a  blurring  of  vision  and 
the  appearance  of  wavy  lines  in  the  atmosphere  was 
always  vastly  relieved  for  a  time  by  partaking  of  a  full 
meal.  Under  careful  treatment  directed  to  the  digestive 
organs,  this  reflex  neurosis  entirely  disappeared. 

In  mydriasis  the  dilatation  of  the  pupil  is  usually  con- 
fined to  one  eye,  and  the  vision  is  much  disturbed. 
Sometimes  it  is  of  organic  origin,  as  a  result  of  certain 
forms  of  brain  disease,  such  as  hydrocephalus,  apoplexy 
at  the  base,  concussion,  etc.  It  is  frequently  intermit- 
tent, especially  when  caused  by  entozoa.  It  often  sub- 
sides spontaneously  or  upon  removal  of  the  causative 
disease. 

The  condition  of  myosis  may  result  from  irritation  of 
the  oculomotor  nerve,  which  in  turn  may  depend  upon 
obstinate  constipation  or  spinal  paralysis.  It  is  often  an 
obscure  affection. 

Photophobia  is  in  some  cases  a  violent  ophthalmic  re- 
flex resulting  from  uterine  disease.  Haziness  and  dim- 
ness of  vision  are  frequently  present  at  the  same  time.  In 
cases  of  chronic  cellulitis  mouches  volantes  are  supposed 
by  very  many  physicians  to  be  reflex  neuroses  dependent 
on  renal  disease,  but  they  are  also  frequently  present  in 
cases  of  endometritis  and  pelvic  cellulitis. 

The  oculo-pupillary  disorders  arising  from  compression 
of  the  cervical  or  upper  portions  of  the  dorsal  cord  gener- 
ally appear  as  a  paralytic  myosis,  and  a  spasmodic  mydri- 
asis. These  symptoms  may  alternate.  In  some  cases  both 
eyes  are  afi'ected ;  in  others  only  one. 

The  cervical  sympathetic  is  very  rarely  the  seat  of  trau- 
matic lesions,  and  hitherto  but  few  cases  have  been  re- 


THE    OPHTHALMIC    KEFLEX    NEUEOSES.  131 

ported.  During  the  American  Civil  War,  Mitchell,  More- 
house, and  Keen  had  under  observation  a  soldier  who 
had  been  shot  behind  the  lower  jaw  on  the  right  side,  at 
the  anterior  border  of  the  sterno-mastoid  muscle.  The 
bullet  made  its  exit  on  the  left  side,  below  and  about  an 
inch  from  the  angle  of  the  lower  jaw.  The  wound  healed 
in  six  weeks.  When  examined  in  the  tenth  week  there 
was  marked  myosis  (especially  when  the  eye  was  shaded) 
of  the  right  pupil.  There  were  also  myopia,  slight  ptosis, 
conjunctival  redness,  and  frontal  pains  on  the  same  side. 
Several  times  an  unusual  redness  of  the  left  side  of  the 
face  was  seen  after  exertion.  While  in  a  state  of  repose 
the  temperature  was  found  normal  in  the  mouth  and  both 
ears.  The  foregoing  symptoms  are  similar  to  those  which 
are  observed  as  resulting  after  experimental  section  of  the 
sympathetic  in  animals. 

Kaempf  (Ges.  d.  Wien.  Aerzte,  March  8th,  1872)  re- 
ported the  case  of  a  soldier  who  was  wounded  in  the  cervical 
region,  and  presented  right  paralytic  myosis  from  injury 
to  the  right  sympathetic.  Galvanization  was  frequently 
tried  without  any  result.  When  the  cervical  region  of 
the  cord  or  the  brachial  plexus  is  wounded  disturbances 
in  the  cervical  sympathetic  may  also  arise.  Hutchinson 
has  observed  unilateral  myosis,  narrowing  of  the  palpe- 
bral fissure,  and  elevation  of  the  temperature  on  the  corre- 
sponding side  of  the  head.  In  addition  to  this,  Seelig- 
muller  {Berliner  klinische  Wochenschrift,  1870  and 
1872)  reports  a  case  with  emaciation  and  atrophy  of  the 
cheek  on  the  same  side  as  the  injur3^  Rosenthal  also  re- 
ports a  case  of  injury  to  the  cervical  cord  with  persistent 
slowness  of  the  pulse  and  very  marked  dilatation  of  the 
left  pupil. 

Observations   upon   fractures  of  the  cervical  vertebrae 


132  FUNCTIONAL   NERVOUS    DISOEDERS. 

have  been  published  by  Rendu,  in  which  other  symptoms 
of  irritation  accompanied  the  unilateral  mydriasis.  In 
luxations  of  the  vertebrae,  hov/ever,  myosis  was  observed, 
with  symptoms  of  paralysis,  as  was  also  found  by  Rosen- 
thal to  be  the  case  in  two  patients  suffering  from  caries  of 
the  odontoid  process.  In  certain  forms  of  ataxia,  and  in 
progressive  muscular  atrophy,  a  considerable  amount  of 
contraction  of  the  pupil  on  the  affected  side  is  generally 
observed.  Periodical  attacks  of  sciatica  are  liable  to 
occur  in  these  cases,  often  with  hypereesthesia  of  the  skin. 
During  these  attacks  spasmodic  mydriasis  sometimes  ap- 
pears upon  the  side  affected.  Here  I  desire  to  mention  the 
great  satisfaction  with  which  I  have  read  the  volume  en- 
titled "Uterus  and  Eye,  a  Treatise  upon  the  Functions 
and  Diseases  of  the  Female  Sexual  Organs  in  their  Patho- 
genic Influence  on  the  Organ  of  Vision,"  by  Dr.  Salo 
Cohn.  This  work  gives  the  whole  subject  in  systematical 
classification,  and  is  so  much  more  to  be  appreciated  as  it 
pays  close  attention  to  a  domain  that  has  up  to  the  present 
time  never  been  thoroughly  cleared.  It  is  therefore  at 
once  theoretically  interesting  and  practically  important 
not  only  to  the  ophthalmologist  and  gynecologist  but  also 
to  the  general  practitioner,  who  may  learn  to  cure  func- 
tional diseases  of  the  eye  by  treatment  of  the  genital 
organs.  This  work  again  shows  how  important  it  is  that 
even  in  devoting  ourselves  to  one  specialty  we  ought  to 
remain  in  close  connection  with  general  medicine.  The 
author  has  also  classified  the  normal  and  pathological 
functions  of  the  female  sexual  organs  and  has  on  a  phj^'si- 
ological  base  shown  the  way  upon  which  the  pathogenic 
influence  reaches  the  brain  and  eye. 

The  conditions  of  pubert}"  and  the  climacteric  which  are 
not  at  all  clear  in  the  minds  of  the  ordinary  practitioner 


THE    OPHTHALMIC    REFLEX    NEUROSES.  183 

have  received  a  thorough  elucidation  and  are  classified 
with  regard  to  their  pathological  features  into  the  chapters 
on  menstrual  anomalies.  When  looking  over  this  work 
we  are  surprised  to  see  how  intensely  normal  menstrua- 
tion as  well  as  pregnancy  and  parturition  may  influence 
all  parts  of  the  visual  apparatus  from  the  lids  up  to  its 
centres.  The  puerperium  and  lactation  play  also  an  im- 
portant role  in  producing  affections  of  the  eye  of  some- 
times a  grave  character.  Finally,  the  question  how  loss  of 
blood  affects  the  organ  of  vision  has  received  exhaustive 
attention.  The  whole  work,  that  brings  two  distant  parts 
of  the  body  in  close  connection,  a  connection  which  is 
formed  by  the  nervous  system,  verifies  to  a  great  extent 
the  theories  and  facts  that  I  have  laid  down  in  this  book, 
which  is  in  a  measure  a  supplement  to  the  before-men- 
tioned work  and  proves  by  many  cases  the  truth  of  his 
premises.  Like  the  author  mentioned  I  also  distinguish 
between  the  general  morbid  condition  of  the  body  that 
may  pathologically  interfere  with  the  normal  functions  of 
an  organ  and  the  pathological  condition  of  a  part  of  the 
body  that  may  cause  disturbances  in  a  distant  organ.  The 
author  gives  precisely  his  standpoint  referring  to  the  gen- 
eral distinction  between  reflex  and  hysteric  action  of  a 
nerve.  He  thinks  that  such  a  distinction  does  not  exist 
at  all  and  that  we  have  to  deal  with  only  one  kind  of  irri- 
tation. 

This  reflex  action  we  recognize  as  such  if  we  find  out  its 
origin,  but  are  we  permitted  to  call  the  irritation  hysteric 
because  we  do  not  find  the  cause?  We  know  very  well  that 
sometimes  the  original  affection,  as  the  author  mentions, 
may  have  disappeared.  The  original  wound  may  have 
healed,  but  the  nervous  irritation,  sensible  or  insensible  to 
the  patient,  may  persist  and  continue,  for  a  time  at  least, 


134  FUNCTIOKALNERVOUS   DISORDERS. 

to  produce  its  evil  effects  upon  the  distant  part  of  the 
body.  I  may  add,  according  to  my  experience,  that  this  is 
the  cause  for  so  many  disorders,  especially  in  the  female, 
that  are  generally  and  falsely  classified  as  hysterical  dis- 
orders. The  electric  current  may  still  influence  the  bell 
through  the  medium  of  the  wire  even  after  we  have  re- 
moved the  pressure  from  the  button.  This  shows  again 
that  we  are  approaching  the  time  when  the  word  hysteria 
will  perhaps  be  entirely  stricken  out  of  medical  termi- 
nology. In  every  case  where  we  find  a  trace  that  leads  us 
to  a  morbid  point,  we  have  certainly  not  the  right  to 
speak  of  hysterical  irritations.  In  all  these  cases  we  have 
to  use  the  term  reflex;  at  the  present  time  we  have  to 
limit  at  least  the  term  hysteria  to  those  conditions  where 
mental  emotions  apparently  play  the  prominent  part  with- 
out any  other  visible  or,  to  our  imperfect  methods,  detect- 
able cause.  The  acceptance  of  this  statement  by  the  profes- 
sion will  tend  to  still  further  clear  up  an  obscure  part  in  the 
disturbances  of  the  nervous  system.  If  we  are  aware  that 
the  so-called  hysteric  condition  is  sometimes  a  grave  affec- 
tion we  shall  in  the  first  instance  try  to  find  out  the  causa- 
tive point,  and  even  if  we  do  not  succeed  we  have  no  right 
to  shrug  our  shoulders  at  such  an  unhappy  patient  and 
declare  all  her  suffering  as  pure  and  simple  imagination. 
"The  evil  is,"  as  Dr.  Cohn  in  his  work  correctly  remarks, 
"  by  no  means  imaginary  but  really  exists,  and  the  patients 
generally  suffer  severely  under  caprices  of  their  ailment 
which  they  try  in  vain  to  master  by  'an  energetic  will.'  " 
I  am  fully  convinced  that  I  am  not  the  only  one  who  on 
the  occasion  of  a  post-mortem  found  out  the  pathologic 
origin  of  the  death  of  a  patient  who  for  many  a  year  was 
treated  for  hysteria,  and  I  remember  a  case  belonging  to 
this  group  where  even  a  large  aneurism  of  the  abdominal 


THE    OPHTHALMIC    KEFLEX    NEUROSES.  135 

aorta  escaped  the  examining  eyes  of  the  physicians  as 
cause  for  the  symptoms  that  went  to  make  the  diagnosis 
"hysteria." 

It  is  interesting  also  that  some  affections  of  the  eye  have 
been  called  hysterical.  Those  that  come  under  observa- 
tion in  connection  with  the  functions  of  the  female  genital 
organs  or  in  connection  with  dysmenorrhoeic  troubles, 
according  to  Dr.  Cohn,  do  not  form  a  separate  category, 
but  belong  rather  to  that  group  of  cases  in  which  a  func- 
tional disturbance  of  the  eye  is  induced  by  reflex  action 
from  a  local  genital  affection.  Can  we,  for  instance,  con- 
sider the  contraction  of  the  visual  field  as  a  support  for  the 
diagnosis  of  hysteria,  if  we  hear  from  the  author  men- 
tioned that  this  same  contraction  is  brought  about  by  the 
menstrual  process  and  is  found  in  a  series  of  other  disor- 
ders? Are  we  justified  in  treating  patients  with  "  hysteric" 
symptoms  in  a  careless  and  contemptuous  manner,  if  we 
read  in  the  same  book  that  after  long  duration  of  such  an 
"  hysterical"  affection  of  the  eye,  where  the  fundus  at  first 
did  not  present  any  perceptible  change,  hypergemia  of  the 
papilla  may  set  in  at  a  time  when  there  is  no  attack,  and 
lastly  may  bring  on  organic  alterations  in  the  optic  nerve? 

Functional  Mydriasis. — Miss  E.,  aged  25,  a  neuras- 
thenic, is  considerably  annoyed  by  intermittent  mj'driasis 
of  the  right  eye,  the  pupil  undergoing  excessive  dilata- 
tion, while  the  iris  in  the  left  eye  remains  in  a  state  of 
inaction.  This  is  caused  b}''  a  spasmodic  action  of  the 
dilator  pupillse,  resulting  from  irritation  of  the  sympa- 
thetic or  the  cerebro-spinal  nerves  communicating  with  it. 
It  is  of  an  ephemeral  character,  and  may  be  a  reflex  from 
either  nasal  disorder  or  some  irritation  in  the  abdominal 
or  pelvic  cavity.  It  may  be  of  the  nature  of  chorea. 
Many  persons,  in  a  nervous  or  slightly  weakened  state, 
have  a  certain  amount  of  twitching  of  the  upper  lid,  due 


136  FUNCTIONAL    NEEVOUS    DISOEDERS. 

to  reflex  irritation.     Helminthiasis  is  often  represented  as 
a  cause  of  ephemeral  mydriasis. 

In  Miss  E.'s  case  weakness  of  the  digestive  organs  is 
probably  the  foundation  of  the  disorder.  Eggs  in  any 
form  always  bring  on  a  severe  attack  of  indigestion,  ac- 
companied by  a  migrainous  headache.  The  application  of 
strong  solutions  of  nitrate  of  silver  to  the  post-nasal  region 
was  followed  by  a  marked  improvement  in  the  digestive 
symptom.  Disagreeable  disturbances  of  accommodation' 
frequently  occur  as  reflexes  in  neurasthenic,  dyspeptic 
persons. 


CHAPTER  XV. 

THE  AURAL  REFLEX    NEUROSES. 

The  aural  reflex  neuroses  are  probably  not  of  great  im- 
portance, still  they  are  of  sufficient  moment  to  be  given  a 
place.     The  following  are  good  examples: 

Aural  Reflex  Neuroses  tvith  Vasomotor  Disorder. — 
Mrs.  McN.,  aged  68.  This  patient's  stomach  has  always 
been  weak,  and  she  now  has  marked  ansemia  from  chronic 
gastro- intestinal  catarrh.  For  the  last  three  months  she 
has  had  a  burning  neuralgia  on  the  vertex,  which  radiates 
all  over  the  head.  Accompanying  this  are  whistlings  and 
noises  in  the  ear  which  are  extremely  armoj^ing.  For  the 
last  two  days  the  sensation  has  been  like  the  snapping  of 
parlor  matches.  She  starts  up  in  the  night  talking  in  her 
sleep.  She  is  costive  and  the  appetite  is  extremeh'  poor. 
Some  slight  improvement  occurred  under  dietetic  treat- 
ment. 

Aural  Reflex  Neuroses.,  Vasomotor  Disturbance; 
Ancemic  Roaring. — Miss  S.,  aged  29,  suffers  every  day 
from  a  roaring  noise  in  the  head  which  is  so  loud  that  she 
imagines  that  people  sitting  in  the  same  room  can  hear  it. 
She  is  very  ansemic,  and  it  takes  but  little  to  make  her 
faint.  She  is  exceedingly^  pale  except  over  the  malar 
prominences,  and  suffers  from  a  very  severe  menorrhagia 
which  is  so  profuse  as  to  often  cause  faintness.  She  has 
pain  on  locomotion,  and  there  is  also  pain  in  the  back  and 
in  the  left  side.  The  roaring  in  her  head  ceases  when  her 
head  is  lowered,  and  she  generallj^  sleeps  without  a  pillow, 
but  her  sleep  is  restless.  She  has  an  excellent  appetite. 
There  is  severe  leucorrhoea.     On  examination,  I  find  the 

137 


138  FUNCTIONAL   NEEVOUS    DISORDERS. 

neck  of  the  uterus  is  occluded  by  a  large  mucous  polypus. 
This  was  removed,  and  the  patient  gradually  recovered 
her  health. 

Unilateral  Ancemic  Roaring. — Mrs.  C.  H.  C.,  aged 
39,  is  far  advanced  in  phthisis.  She  is  excessively  anae- 
mic; her  expectoration  is  viscid  and  exceedingly  copi- 
ous. She  experiences  the  most  distress  from  an  intermit- 
tent sensation  of  loud  roaring  in  the  right  ear  and  the 
whole  of  the  right  side  of  the  head.  She  complains  more 
of  this  and  is  more  anxious  for  its  relief  than  for  that  of 
any  other  symptom.  It  is  quite  evident  to  my  mind  that 
the  inflammatory  disorder  of  the  left  lung  is  the  source  of 
this  trouble  and  that  the  irritation  is  transmitted  through 
the  decussation  of  nerve  fibres  in  the  spinal  column  {de- 
cussatio  pyramidum)  to  the  right  side  of  the  head  in  the 
floor  of  the  fourth  ventricle.  The  auditory  nerve,  through 
which  in  this  case  the  irritation  is  manifested,  takes  its 
origin  in  the  floor  of  the  fourth  ventricle.  Pathology  here 
demonstrates  what  microscopical  anatomy  teaches.  Care- 
ful examination  of  the  ear  showed  no  local  disorder 
present. 

Under  a  superficial  examination  of  this  case  the  practi- 
tioner would  be  apt  to  consider  it  a  purely  local  disorder, 
and  direct  his  treatment  to  the  ear,  giving  no  attention 
whatever  to  the  chest  and  abdominal  cavity,  which  should 
always  be  interrogated  when  obscure  aural  symptoms  are 
present. 

A  common  reflex  from  the  auditory  nerve  is  the  sensa- 
tion which  is  popularly  known  as  "  setting  the  teeth  on 
edge,"  and  arises  from  harsh  and  scratching  noises;  the 
effect  being  generally  more  pronounced  on  the  person  who 
causes  the  sounds,  perhaps  on  account  of  the  irritation 
being  transmitted  in  a  measure  also  through  the  spinal 
column.  These  sensations  are  intensified  in  those  who  are 
anaemic  and  sensitive. 


THE    AURAL    REFLEX    NEUROSES.  139' 

In  some  cases  of  ansemia,  from  insufficient  or  improper 
diet,  along  with  mental  worry,  the  patients  suffer  attacks, 
of  a  peculiar  nature.  Immediately  following  a  slight  sen- 
sation of  fear  or  depression  there  is  a  hypersesthesia  of  all 
the  special  senses.  If  the  patient  is  walking  in  the. 
streets,  the  sound  of  her  own  and  others'  footsteps  is  most 
distressing ;  people  seem  to  rush  by  her  with  great  vio- 
lence, or,  if  they  remain  behind,  she  fears  they  are  about 
to  pounce  upon  her;  their  movements  seem  to  be  distress- 
ingly energetic  and  extremely  rapid.  If  riding  in  a  horse- 
car  or  other  vehicle,  the  sensation  of  a  very  rapid  and  dan- 
gerous pace  is  experienced  when  the  horses  are  merely 
going  at  a  slow  trot.  It  is  all  hallucination,  but  reasoning 
and  knowledge  of  its  incorrectness  do  not  remove  it.  The 
tongue  also  is  in  a  state  of  extreme  sensitiveness.  Distant 
and  insignificant  sounds  are  fancied  to  be  in  the  immedi- 
ate vicinity  of  the  patient,  and  of  deafening  volume;  and 
even  the  vision  seems  to  be  somewhat  sharpened.  These 
manifestations  are  unaccompanied  by  any  sensation  of 
pain. 


CHAPTER  XVI. 

LINGUAL  REFLEX  NEUROSES. 

Cases  of  lingual  neuralgia,  without  any  objective  signs 
of  inflammatory  action  being  present  in  the  tongue,  are 
often  very  severe  and  obstinate.  Of  the  reflex  and  neural- 
gic character  of  this  disorder  there  can  be  no  doubt. 
Local  applications,  as  a  rule,  afford  no  relief.  It  is  some- 
times remarkably  persistent,  lasting  in  some  cases  for 
years.  It  is  more  common  in  women  than  in  men.  One  of 
my  patients  who  has  suffered  with  this  disorder  never  ex- 
perienced an  attack  unless  -she  visited  a  certain  fashionable 
watering-place,  when  within  twenty-four  hours  an  attack 
always  came  on  with  great  severity.  Her  teeth  are  good 
and  well  cared  for,  and  there  is  no  sign  of  local  disease  of 
the  tongue.  It  is  natural  in  color  and  normal  in  size, 
without  an.y  indentation  of  its  edges.  The  tongue  is 
peculiarly  susceptible  to  nervous  influences  of  either  an 
organic  or  functional  character.  This  is  seen  in  the  uni- 
lateral coating  occurring  in  cases  of  hemiplegia  resulting 
from  cerebral  hemorrhage,  while  the  stammering  in  cases 
of  mental  fatigue  is  probably  due  in  a  degree  to  a  lack  of 
nervous  strength  in  the  organ.  The  neuralgia  is  most 
common  in  neurasthenic  and  melancholic  patients  with 
imperfect  digestion.  Some  women  suffer  from  it  only 
during  pregnancy.  In  some  cases  the  patients  experience 
great  difficulty  in  articulation,  and  the  taking  of  any  food 
except  in  a  liquid  form  is  impossible,  owing  to  the  severe 

pain  experienced.  . 

140 


LINGUAL    REFLEX    NEUROSES.  141 

Burning  sensations  in  the  tongue  are  not  uncommon  re- 
flex sensations  in  women.  They  are  often  of  hysterical 
origin,  and  care  must  be  taken  to  differentiate  them  from 
similar  sensations  accompanying  inflammatory  conditions. 
In  the  superficial  forms  of  glossitis  the  tongue  is  dry, 
glazed,  exceedingly  red  and  tender  with  an  accompanying 
burning  sensation.  When  the  inflammation  is  deeply 
seated  there  is  often  much  swelling. 

In  the  treatment,  a  tonic  regimen  should  be  carried  out, 
and  Fowler's  solution  in  five-drop  doses  given  three  times 
daily  combined  with  quinine  five  grains.  Iodide  of  potas- 
sium may  also  be  given  in  small  doses.  In  some  cases  Dono- 
van's solution  may  be  of  value,  or  pills  of  the  carbonate  of 
iron  and  gentian,  freshly  made.  Blaud's  pills,  as  ordinarily 
sold  in  the  drug  stores,  like  the  quinine  pills,  are  often  so 
insoluble  that  they  are  of  little  use. 

Dr.  John  Hilton,  in  his  work  on  "Rest  and  Pain,"  men- 
tions the  following  cases,  which  are  interesting  in  this  con- 
nection : 

Furred  Tongue  on  One  Side,  Depending  on  Disease 
luithin  the  Cranium, — "  The  first  time  I  had  an  oppor- 
tunity of  clearing  up  such  a  case  as  this  occurred  in  1843. 
On  December  17th,  1843, 1  examined,  with  Mr.  Blenkarne, 
a  surgeon  in  the  city,  the  body  of  one  of  his  patients,  who 
had  died  with  disease  of  the  brain  and  spine.  She  had 
suffered  from  intense  pain  on  the  left  side  of  the  head. 
She  had  also,  during  her  life,  a  tongue  furred  on  the  left, 
and  scarcely  at  all  on  the  right  side.  It  became,  therefore, 
an  important  point  to  clear  up  what  was  the  probable  cause 
of  that  condition  of  the  tongue.  We  made  a  post-mortem 
examination  and  found,  as  was  anticipated,  a  diseased 
spine.  Then,  upon  very  careful  examination  of  the  head, 
on  turning  up  the  dura  mater  from  the  anterior  part  of 
the  petrous  portion  of  the  left  temporal  bone,  for  the  especial 


142  FUNCTIOIfAL   NERVOUS    DISORDERS. 

purpose,  we  exposed  the  Gasserian  ganglion,  or  the  gang- 
lion of  the  fifth  nerve.  We  there  found  what  might  be 
called  a  scrofulous  deposit  upon  the  convex  edge  of  this 
ganglion,  involving  the  second  division  of  the  fifth  nerve 
more  than  the  third,  but  still  involving  all  more  or  less. 
Here,  then,  appeared  to  us  to  be  the  probable  explanation 
of  the  tongue  furred  on  its  left  side.  This  observation 
was  made  in  1843 ;  the  disease  was  near  the  ganglion  of 
the  fifth  nerve,  and  on  the  same  side  as  the  furred  tongue. 
-If  I  should  not  mention  the  fact  again,  it  will  be  clearly 


T'iG.  11. — Sketch  of  a  tongue  furred  only  on  the  left  side,  resulting  from  a  de- 
cayed and  painful  second  molar  tooth  in  the  upper  jaw  of  the  same  side  of 
the  head. 

understood  that  the  diseased  condition  of  the  tooth,  or  of 
the  fifth  nerve,  was  always  found  on  the  same  side  as  the 
furred  tongue,  and  that  the  fur  was  confined  to  the  an- 
terior two-thirds  of  the  upper  surface  of  the  tongue,  over 
the  distribution  of  the  lingual  gustatory  nerve — a  portion 
of  the  third  division  of  the  fifth." 

Furred  Tongue  on  One  Side  Caused  by  a  Decayed 
Tooth  on  the  Same  Side. — "The  sketch  (Fig.  11)  is  of  a 
tongue  furred  on  one  side,  and  comparatively  clean  on  the 
other.  This  furred  condition  of  the  tongue  is  frequently 
■associated  with  a  diseased  condition  of  the  second  and 
third  divisions  of  the  fifth  nerve.  It  is,  in  fact,  a  func- 
tional and  structural  deterioration  depending  upon  ner- 
vous influence. 


LINGUAL    REFLEX    XEUROSES.  143 

"  Recentlj',  a  lady,  whom  I  have  known  for  some  years, 
consulted  me  regarding  some  matters  not  of  importance, 
and  I,  perhaps  not  for  any  very  precise  purpose,  said,  'Let 
me  look  at  your  tongue. '  She  put  out  her  tongue,  and  it 
was  furred  on  one  side.  I  said,  'You  have  a  bad  tooth,' 
and  she  thought  it  was  exceedingly  clever  on  my  part. 
'Yes,'  she  replied,  'and  I  am  going  to  Mr.  Bell  to  have 
it  taken  out. '  She  went  and  had  it  extracted ;  I  saw  her 
a  fortnight  afterward,  and  all  the  fur  had  subsided. 
This  was  a  second  molar  tooth  in  the  upper  jaw  of  the 
same  side  as  the  furred  tongue." 

I  have  also  seen  the  side  of  the  tongue  coated  from  tip 
to  base  from  toothache,  while  the  centre  and  other  side 
were  quite  normal  in  color. 
10 


CHAPTER  XVII. 

THE   ARTICULAR  REFLEX  NEUROSES. 

Pain  in  the  hip,  knee,  ankle,  shoulder,  elbow,  and  wrist 
is  often  a  transferred  pain  or  of  reflex  origin.*  Many  cases 
of  hysterical  joint  are  undoubtedly  true  neuroses,  but  they 
are  very  puzzling  symptoms,  and  require  careful  investiga- 
tion and  treatment  of  both  the  digestive  and  reproductive 
organs  before  they  become  manageable.  Pain  in  the  knee 
is  commonly  associated  with  uterine  disease.  An  anky- 
losis of  the  knee-joint,  or  a  lameness,  may  be  either  a 
psychosis  or  a  gastric  or  uterine  reflex.  A  laceration  of 
the  cervix,  accompanied  by  a  local  inflammation  upon  one 
side  of  the  uterus,  has  been  known  to  produce  pain  and 
stiffness  in  the  knee  of  the  same  side.  Pain  and  tender- 
ness at  the  hip-joint,  simulating  hip  disease,  may  result 
from  uterine  disorder,  thus  showing  its  reflex  nature. 
Pains  in  the  wrist  and  ankle  have  been  spoken  of  as  of 
ovarian  origin.  They  usually  exist  upon  the  same  side 
as  the  affected  ovarv. 


*  A  most  learned  clergyman,  whom  I  am  treating,  tells  me  that 
when  a  youth  at  the  "hobbledehoy"  age  he  was  exceedingly  shy, 
and  whenever  called  upon  to  present  liimself  prominently  to  the 
gaze  of  others,  he  was  immediately  seized  with  an  intense  weakness 
in  the  knees.  This  was  so  severe  on  one  occasion  as  to  cause  him 
to  fall  flat  upon  the  floor.  He  was  also  the  victim  of  morbid  blush- 
ing. 

144 


THE    ARTICULAK    KEFLEX    XEUROSES.  145 

Stiffness  of  the  joints  of  the  lower  extremities  has  been 
noted  as  an  accompaniment  of  menstruation  in  cases  of 
pelvic  inflammation,  coming  on  shortly  before  the  cata- 
menial  flow,  increasing  with  its  height  and  disappearing 
with  its  cessation. 

Dr.  John  Hilton  gives  the  following  explanation  of 
hysterical  pain  in  hip  or  knee  joint : 

"  The  sacral  ganglia  and  the  lower  lumbar  ganglia  of  the 
sympathetic   nerve  are  connected  with  the  great   sciatic 
nerve,  and  partly  also  with  the  obturator  nerve.     These 
same  ganglia  are  connected  likewise  with  the  nerves  pro- 
ceeding through  the  broad  ligament  to  the  uterus  and  to 
the  ovaries.     I  think  we  have  here,  then,  an  explanation 
of  the  frequent  occurrence  of  what  we  call  hysterical  hip- 
joint  or  hysterical  knee-joint.     If  the  nerves  in  the  ovaries 
or  the  uterus  be  in  a  state  of  irritation,  that  irritation  can 
be  conducted  to  these  sacral  nerves  or  to  the  obturator,  and 
then,  in  accordance  with  the  generally  received  law  of 
distribution  of  nervous  influence,  irritation  or  pain  may  be 
manifested  at  the  other  peripheral  or  articular  end  of  the 
same  nerve.     Hence  it  may  be  expressed  within  the  knee- 
joint,  on  the  inner  side  of  the  knee-joint,  or  it  may  be 
within  the  hip-joint,  because  the  hip-joint  as  well  as  that 
of  the  knee  receives  its  nerves  from  these  various  sources. 
The  posterior  part  of  the  hip-joint,  you  will  remember,  has 
nerves  coming  to  it  from  the  sacral  plexus.     The  sacral 
plexus  receives  some  filaments  from  the  sacral  ganglia ;  so 
do' the  uterine  and  ovarian  nerves;  and  it  is  quite  possible, 
nay,  I  think  is  very  likely,  that  the  irritation  commenc- 
ing in  the  ovaries  or  the  uterus  might  be  conveyed  to  some 
of  the   filaments  derived  from  the   same  ganglia  in  the 
sacrum,  and  irritation  in  the  hip-joint  be  thus  produced. 

You  will  observe  that  the  two  nerves,  which  are  so  dis- 
10 


146  FUXCTIOXAL   XERTOUS    DISORDERS. 

tributed  as  to  be  capable  of  producing  the  pain  in  the 
joints,  are  the  great  sciatic  and  the  obturator;  and  I  be- 
lieve this  is  a  probable  explanation  of  the  fact  that  of  all 
the  joints  in  the  human  body  affected  hysterically  as  we 


Fig.  12.— a.  Spinal  cord.  6,  Spinal  nerves  ^oing  to  the  posterior  part  of  the  hody 
behind  the  vertebral  column,  c,  A  visceral  artery  accompanied  by  branches  of 
the  sympathetic  nerve,  d.  Common  spinal  nerve,  composed  of  motor  and 
sensory  filaments,  e,  Portion  of  intestine  (uterus  or  ovary)  receiving  minute 
filaments  from  the  spinal  nerves  and  sympathetic  nerve.  /,  Ganglia  of  sympa- 
thetic nerve,  united  to  each  other  by  longitudinal  filaments,  and  receiving 
branches  from,  as  well  as  giving  oil  branches  to,  a  common  spinal,  motor, 
and  sensory  nerve. 

The  arrows  indicate  the  directions  which  any  intestinal,  uterine,  or  ovarian 
irritation  might  pursue  centrifugally,  either  directly  backward  to  the  skin  in 
that  region,  or  along  a  spinal  nerve  to  its  muscular,  articular,  or  cutaneous 
destination. 

term  it,  none  are  so  frequently  involved  as  those  of  the 
hip  and  the  knee.  Sir  J.  Paget,  to  whose  lot  it  has  fallen 
to  see  more  of  these  cases  than  to  any  other  surgeon,  save 
perhaps  the  late  Sir  B.  Brodie,  speaks  as  follows  in  his 
'  Clinical  Lectures  and  Essays,'  edited  by  Howard  Marsh, 
p.  197 :  '  Among  all  the  joints,  the  hip  and  the  knee, 
which  are   the  most   frequent  seats  of  real   disease,  are 


THE    AETICULAR    REFLEX    NEUROSES.  147 

equally  so  of  the  mimicry — a  fact  not  easy  to  account  for. 
It  may  be  clue  to  mental  association,  perhaps  unconsciously, 
or  to  a  mingled  inheritance — for  instance,  to  an  inheri- 
tance of  nervous  constitution  and  of  relative  weakness  in 
the  joint  or  joints  most  weak  in  progenitors.'  By  tracing 
these  two  nerves,  I  think  we  may  find  a  probable  interpre- 
tation of  that  frequency.  I  haA^e  here  constructed  a  dia- 
gram intended  to  represent  what  I  have  been  alluding  to. 
Suppose  this  (/)  to  represent  the  three  ganglia  of  the  sym- 
pathetic ;  we  have  then  a  spinal  nerve  (c/)  attached  to  the 
spinal  cord,  and  taking  its  onward  course  to  the  muscles 
and  the  skin.  We  know  that  these  spinal  nerves  commu- 
nicate with  the  ganglia,  and  so,  by  the  sympathetic 
branches  travelling  along  the  arteries  (c) ,  reach  the  intes- 
tine (e),  uterus,  and  ovaries.  Let  us  assume,  then,  that  a 
patient  may  have  irritation  from  any  cause  in  the  intes- 
tine, in  the  uterus  or  ovaries,  or  in  the  broad  ligaments. 
On  this  map  we  may  trace  the  course  of  that  intestinal, 
uterine,  or  ovarian  irritation  through  the  ganglia,  through 
the  spinal  nerve  and  spinal  marrow,  thence  to  be  reflected 
to  any  part  of  the  peripheral  or  articular  distribution  of 
that  same  spinal  nerve.  This  condition,  I  apprehend,  is 
sometimes  very  clearly  recognized  in  the  case  of  the  in- 
testines. Who  is  there  that  has  not  felt  griping  pains  in 
the  interior  of  the  intestines  from  some  morbid  agent  lying 
there,  or  from  drastic  purgatives  traversing  the  gut,  ac- 
companied by  pains  or  cramps  in  the  leg,  and  pains  in  the 
loins? — conveyed  in  the  latter  instance  by  the  filaments  of 
spinal  nerves,  which  pass  to  the  posterior  part  of  the  body 
or  the  lumbar  region.  And  is  it  not  a  common  occurrence 
in  cases  of  uterine  and  ovarian  irritations  for  the  patients 
to  complain  of  pain  in  the  joints,  but  particularly  over  the 
posterior  part  of  the  sacrum?     The  ovarian  and  uterine 


148  FUNCTIONAL   NERVOUS    DISORDERS. 

nerves  traverse  the  ganglia  of  the  sympathetic,  and  so 
reach  the  spinal  nerves.  Hence  the  morbid  influence  con- 
veyed by  the  posterior  branches  of  the  spinal  nerves  to  the 
skin  over  the  lumbar  and  sacral  regions  explains  the  lum- 
bar and  sacral  pains  experienced  by  such  patients." 


CHAPTER  XVIII. 
THE  DERMAL  REFLEX  NEUROSES    OR  DERMATOSES. 

A  VERY  definite  relation  exists  between  the  skin  and  the 
internal  organs.  In  cases  where  a  derangement  of  the 
stomach,  liver,  kidney,  or  uterus  coexists  with  a  skin  dis- 
ease, the  removal  of  the  internal  disorder  frequently  causes 
the  disappearance  of  the  cutaneous  affection.  This  results 
from  the  intimate  functional  interdependence  of  the  vari- 
ous parts.  In  the  treatment  of  all  skin  disorders  special 
attention  should  be  given  to  what  physiology  teaches — 
that  is,  the  intimate  connection  between  the  functions  of 
the  skin,  liver,  and  kidneys.  Imperfect  digestion  and  in- 
efficient renal  elimination  are  the  causes  of  one-half  of  all 
skin  diseases,  and  this  is  particularly  noted  in  gouty  and 
rheumatic  subjects. 

The  connection  between  dermatoses  of  the  face  (such  as 
acne  and  chronic  redness)  and  uterine  and  digestive  de- 
rangements is  noted  by  all  practitioners. 

Many  of  the  dermatoses  are  merely  symptoms  of  general 
diseases  whose  chief  seat  is  the  internal  organs.  Such 
affections  are  said  to  be  often  the  results  of  faecal  impac- 
tion. 

Among  the  reflex  neuroses  of  the  skin  are : 

1st.  Hypersesthesia. 

2d.  Ansesthesia. 

3d.  Perverted  sensibility. 

Under  the  heading  of  neurotic  disease  of  the  skin  may 

149 


150  FUXCTIONAL    NERVOUS    DISORDERS. 

be  classed  pruritus,  prurigo,  urticaria,  herpes,  acne  ro- 
sacea, lichen. 

Pruritus  as  a  reflex  neurosis  is  frequently  dependent 
upon  gastro-intestinal  and  genito-urinary  disturbances. 
Rich,  stimulating,  and  indigestible  diet,  intestinal  para- 
sites, and  many  digestive  and  uterine  derangements  are 
among  the  common  causes  of  this  disorder.  The  itching 
may  be  general  or  local ;  in  digestive  disorders  it  is  usu- 
alljT-  the  extremities  which  are  most  affected,  although  the 
entire  surface  of  the  body  may  be  involved.  Among  the 
varieties  of  its  local  manifestations  are:  Pruritus  ani, 
pruritus  vulvae,  pruritus  urethrse,  pruritus  nasi. 

Prurigo  as  a  reflex  dermatosis  is  common  in  advanced 
life.  The  itching  is  of  a  peculiar,  burning,  tingling  char- 
acter, aggravated  by  friction.  It  may  be  partial  or  gen- 
eral, and  is  most  common  on  the  back,  the  outside  of  the 
limbs,  and  in  the  region  of  the  anus  and  genital  organs. 

The  most  common  causes  of  this  affection  are  improper 
diet  and  unhygienic  living.  Prurigo  of  the  anus  and 
vulva  undoubtedly  depends  upon  obstruction  of  the  portal 
circulation  from  congestion  of  the  liver.  It  is  commonly 
present  in  persons  of  intemperate  habits,  and  is  frequently 
very  severe  and  recurrent  during  the  menopause. 

Eruptions  which  appear  at  puberty  have  been  known 
to  come  again  at  the  menopause,  while  in  the  mean  time 
the  patient  has  been  free  from  any  similar  affection. 
Some  writers  on  diseases  of  the  skin  have  recognized  the 
reflex  nature  of  some  of  the  dermatoses,  but  they  simply 
consider  them  part  of  the  general  morbid  condition.  Many 
of  the  digestive  and  sexual  changes  in  women  are  accom- 
panied by  disorders  of  the  skin.  It  is  common  to  see 
women  affected  with  uterine  or  digestive  disorder  suffer- 
ing at  the  same  time  from  eczema  facialis,  acne,  or  urticaria, 


THE    REFLEX    DERMATOSES.  151 

whicli  does  not  subside  under  the  ordinary  forms  of  treat- 
ment, and  only  disappears  on  removal  of  the  uterine  or 
digestive  disorder.  Reflex  dermatoses  dependent  upon 
the  menstrual  disturbance  manifest  themselves  some- 
times by  a  small  red  surface  on  the  side  of  the  nose,  cheek, 
chin,  or  other  portions  of  the  surface  of  the  body.  These 
patches  may  be  erythematous,  or  sometimes  pustular  in. 
their  nature.  Others  are  diffuse  inflammatory  eruptions, 
and  are  called  by  some  physicians  chronic  recurrent  erysip- 
elas (the  erysipele  catameniel  of  the  French  writers). 
There  is,  however,  nothing  erysipelatous  about  the  eruption. 
Ecchymoses  and  hemorrhagic  spots  have  been  noted  by 
writers  as  recurring  regularly  at  the  menstrual  period. 
The  causative  connection  between  catarrhal  conditions  of 
the  uterine  or  digestive  organs  and  these  cutaneous  erup- 
tions is  readily  distinguished.  A  case  is  on  record  of  a 
young  woman  whose  first  appearance  of  menstruation 
was  accompanied  by  hemorrhagic  perspirations  which 
recurred  regularly  at  each  menstrual  period  until  she  be- 
came pregnant,  when  the  perspirations  ceased,  never  to 
return. 

Symptomatic  chloasmata  are  always  dependent  upon 
some  internal  disorder.  Chloasma  uterinum  generally 
appears  as  a  brownish  discoloration  on  the  abdomen,  fore- 
head, or  cheeks.  Sometimes  it  is  so  pronounced  that  the 
patient  appears  as  if  wearing  a  mask.  This  affection  may 
present  a  very  dark  hue,  even  black,  or  the  discoloration 
may  be  so  light  in  color  as  to  be  scarcely  noticeable. 
Cutaneous  discolorations  of  this  type  are  common  in 
patients  with  digestive  disorders  and  in  those  suffering 
from  cancerous  affections. 

Reflex  dermatoses  as  a  rule  receive  but  slight  attention 
from  the  gynsecologist.     Sudden  changes  of  the  complexion 


152  FUNCTIONAL   NEKVOUS    DISORDERS, 

of  a  most  marked  character  are  readily  recognized  by  even 
the  laity  as  a  result  of  the  correction  of  digestive  disease, 
or  as  following  a  beneficial  operation  upon  the  uterus  or 
its  appendages. 

The  sallow  countenance  present  in  liver  derangements 
may  be  a  true  neurosis.  It  generally  yields  readily  to  the 
treatment  of  the  causative  hepatic  disorder.  In  some  cases 
of  pregnancy  the  pigmentation  does  not  extend  beyond  the 
linea  alba  and  the  areola  of  the  breasts,  while  in  a  great 
number  of  others  the  face  is  as  strongly  marked. 

Among  the  common  dermatoses  of  puberty  are  acne  and 
seborrhoea.  Acne  is  more  often  functional  than  organic. 
It  occurs  usually  about  the  establishment  of  puberty,  and  is 
dependent  upon  physiological  changes  that  have  a  patho- 
logical accompaniment;  it  is  also  commonly  induced  by 
digestive  derangements,  and  exists  as  a  dermatic  reflex  in 
patients  who  indulge  freely  in  alcohol,  and  in  those  with 
some  forms  of  dyspepsia.  Uterine  disease  is  sometimes 
productive  of  acne  in  its  severest  form. 

Seborrhoea  is  sometimes  dependent  upon  disorders  of 
digestion  alone,  while  at  other  times  pathological  condi- 
tions of  the  genital  apparatus  are  its  causative  agents. 
Attention  to  regimen,  laxatives,  and  local  uterine  treat- 
ment rarely  fail  in  causing  its  speedy  removal. 

The  beautiful  complexions  of  girls  with  perfect  digestive 
apparatus  are  most  commonly  seen  in  the  youthful  peasant 
emigrants  from  Great  Britain  and  Ireland  arriving  on 
our  shores.  This  is  not  alone  the  result  of  good  nutrition 
and  healthy  blood,  but  is  a  proof  that  no  uterine  or  diges- 
tive derangement  exists  to  cause  neurotic  disturbances  in 
the  appearance  of  the  skin. 

In  some  forms  of  uterine  disease  the  abdomen  may  turn 
almost  black,  while  in  others  it  is  mottled  or  grayish  in 


THE    REFLEX    DERMATOSES.  153 

appearance.  This  pigmentation  disappears  when  proper 
treatment  is  instituted. 

Acne  rosacea  in  a  severe  form  is  a  very  common  com- 
plaint with  farmers'  wives  who  live  upon  a  bad  diet,  con- 
sisting of  fried  meats  and  an  abundance  of  indigestible 
pastry.  Herpes  of  the  pudenda  has  been  noted  in  cases  of 
metritis,  and  is  here  undoubtedly  a  reflex  nervous  symptom. 

In  patients  suffering  from  dysmenorrhoea,  tumefactions 
about  the  size  of  a  small  walnut  frequently  appear  in  vari- 
ous parts  of  the  body  as  reflex  manifestations.  In  some 
of  these  patients  at  the  menstrual  period  the  breasts  become 
intensely  painful,  and  there  is  often  numbness  and  tingling 
of  the  fingers. 

Mrs;  P.  (Fig.  13),  aged  43,  has  been  subsisting  for  a  con- 
siderable time  upon  indigestible,  badly  cooked  carbohy- 
drate food.  She  is  quite  weak  and  unable  to  do  any  phys- 
ical labor  without  resting  frequently.  Every  afternoon  she 
is  obliged  from  exhaustion  to  lie  down  for  a  number  of 
hours.  She  is  mentally  depressed,  and  suffers  much  from 
fermentative  dyspepsia,  iiatulence  being  an  exceedingly 
annoying  sj'mptom.  Her  chest  is  covered  by  patches  of 
chloasma,  circular  in  form,  and  varying  in  size  from  that 
of  a  pea  to  an  orange;  the  color  is  brown.  Under  treat- 
ment directed  to  her  liver  and  rectifying  her  diet,  these  dis- 
colorations  rapidly  disappeared.  She  was  given  a  drachm 
of  sodium  phosphate  in  hot  water,  three  times  daily,  an  hour 
before  food. 

A  Menstrual  Dermato-Neurosis. — Fig.  14  iUustrates 
a  case  of  menstrual  dermato-neurosis  of  the  face  which 
came  under  the  care  of  Dr.  George  M.  Edebohls,  and  was 
reported  by  him  (Transactions  of  the  New  York  Obstet- 
rical Society,  November  loth,  1892).  Between  the  ages 
of  fifteen  and  nineteen  this  patient  suffered  from  dysmen- 
orrhoea and  an  eruption  on  the  right  side  of  the  face,  as 
seen  in  the  illustration.     There  was  an  interval  of  eight 


154 


FUS"CTIOXAL   IS^ERVOUS   DISORDERS. 


months  when  she  was  about  eighteen,  during  which  neither 
the  eruption  nor  the  dysmenorrhoea  appeared.  Dr.  Ede- 
bohls  treated  her  on  December  22d,  1891,  for  endometritis 


Fig.  13. 


and  catarrhal  salpingitis,  by  dila,tation  of  the  cervix, 
curettage,  and  gauze-drainage  of  the  uterus.  The  result 
was  the  complete  disappearance  of  the  dysmenorrhoea  and 
eruption  for  the  space  of  three  months.  They  reappeared 
again,  and  three  months  later  he  found,  on  examination. 


THE    REFLEX    DERMATOSES. 


155 


small  cystomata  of  both  ovaries,  which  had  not  been 
present  before.  On  June  28th,  1892,  he  performed  double 
ovariotomy  and  ventro- fixation  of  the  uterus.  Two, poly- 
cysts,  one  of  the  left  ovary,  ten  centimetres  in  diameter, 
and  one  of  the  right,  six  centimetres  in  diameter,  were  re- 
moved.    Since  the  operation,  six  months  ago,  the  patient 


K»«*«*^' 


Fig.  14. 


has  not  menstruated  or  suffered  any  pelvic  pain.  The 
eruption  of  the  face,  however,  has  returned  regularly  every 
month,  and  is  rather  more  pronounced  than  formerly. 
On  one  occasion  it  extended  around  to  the  left  side  of  the 
face. 

The  future  developments  will  demonstrate  whether  the 
phenomenon  is  to  be  regarded  as  a  molimen  menstruale. 


Treatment. — The  curative  measures  must  be  first  di- 
rected to  the  correction  of  the  mode  of  living  and  general 


156  FUNCTIOXAL   NEEYOUS    DISORDEES. 

hygiene,  when  these  are  found  to  be  improper.  The  diet 
should  be  nourishing  but  not  too  stimulating,  and  the  use 
of  all  alcoholic  beverages  should  be  strictly  forbidden. 
Alkaline  baths  should  be  taken,  and  the  strictest  cleanli- 
ness enforced. 

With  regard  to  internal  treatment,  the  dilute  hydro- 
chloric acid  before  meals  will  be  found  very  beneficial,  as 
will  also  strychnine.  Arsenic  may  be  often  used  with  ad- 
vantage in  the  form  of  either  Fowler's  or  Donovan's  solu- 
tion. The  bowels  should  be  carefully  regulated.  The 
local  measures,  for  the  purpose  of  allaying  the  itching  when 
present,  may  be  the  application  of  lotions  or  salves.  A 
wash  of  liquor  plumbi  subacetatis  with  a  little  opium  may 
be  employed,  or  one  containing  bichloride  of  mercury  or, 
better  still,  a  strong  emulsion  of  kretol  (this  is  especially 
useful  in  pruritus  ani) .  Ointments,  made  on  the  same  prin- 
ciples, or  containing  belladonna,  camphor,  or  opium,  may 
also  be  used,  and  are  often  of  service  when  the  lotions  fail 
to  give  relief. 


CHAPTER    XIX. 

HYSTERIA. 

Among  the  imitations  of  organic  disease  which,  in  one 
or  another  of  its  many  forms,  we  are  liable  at  any  time  to 
meet  in  our  practice,  is  hysteria.  Any  or  every  part  of 
the  body  may,  under  the  influence  of  the  nervous  system, 
be  its  seat ;  in  my  opinion  it  has  not  received  the  careful 
attention  which  it  deserves,  although  much  has  been  writ- 
ten upon  the  subject.  There  are  many  physicians  engaged 
in  active  practice  who  give  it  scarcely  a  passing  thought. 
The  mind  of  the  average  practitioner  is  taken  up  with  the 
pathological  changes  going  on  in  the  body.  Congestion, 
inflammation,  and  their  results  attract  all  his  attention, 
and  he  almost  altogether  ignores  functional  disturbances. 

Hysteria  is  an  objectionable  name,  as  the  brain  rather 
than  the  uterus  is  the  organ  involved.  To  find  a  suitable 
substitute,  however,  is  extremely  difficult ;  common  usage 
has  given  the  name  hysteria  to  certain  forms  of  nervous 
irritation,  and  we  therefore  accept  it. 

Many  cases  of  spinal  tenderness,  which  is  a  simple  func- 
tional disorder,  a  reflex  from  digestive  or  other  abdominal 
disturbance,  have  been  supposed  to  be  local  or  other  in- 
flammatory diseases,  and  have  been  treated  by  confinement 
to  bed,  blisters,  and  other  local  remedies,  when  no  disease 
was  present  in  the  part  under  observation. 

Contractures  of  the  hand  or  foot,  of  supposed  organic 

origin,  have  often  been  met  with,  when  hj^steria  was  alone 

157 


158  FUNCTIONAL    NEKVOUS    DISORDEES. 

the  cause  of  their  production.  A  very  large  number  of  the 
diseases  in  women  of  all  classes  is  of  hysterical  origin. 
This  explains  the  marvellous  results  obtained  from  the 
many  and  various  methods  of  treatment  in  vogue;  at 
present  electricity  is  the  general  cure-all,  and  a  short  time 
hence  some  other  medical  fad  will  probably  be  the  fashion. 
Simulated  or  unconsciously  feigned  disease  might  be  said 
to  be  the  rule,  while  inflammatory  disease  is  the  exception. 
Hysteria  may  usuallj^  be  traced  to  some  constitutional 
weakness  or  to  exhaustion  of  mind  or  body  with  some  ac- 
companying marked  mental  emotion.  Anything  which 
powerfully  excites  the  intellectual  sphere,  such  as  severe 
mental  shock,  excessive  stimulation  and  indulgence  of  the 
imagination  and  emotions,  tends  to  the  development  of 
hysteria. 

Hysteria  occurs  frequently  in  epidemics,  of  which  med- 
ical history  gives  several  examples.  Life  in  dreary  mo- 
notonous surroundings,  such  as  prisons  or  isolated  farms, 
results  in  the  production  of  much  hysteria  and  insanity. 
From  the  never-changing  gloom,  the  lack  of  social  inter- 
course, and  the  ceaseless  repetition  of  a  daily  routine,  these 
surroundings  are  as  destructive  to  mental  as  to  physical 
health.  The  hysterical  are  as  a  rule  anaemic,  nervous 
people,  who  are  fretful,  emotional,  and  quick-tempered. 
It  is  not  alone  the  emaciated  ansemics  who  suffer  from  the 
disease,  but  fat  women  with  hj-draemia  are  its  frequent 
victims.  Impaired  digestion,  the  result  of  defective  hy- 
giene and  bad  cookery,  is  a  primary  cause  of  anaemia,  and 
the  basis  of  most  of  the  cases  under  consideration. 

The  seeds  of  hysteria  exist  in  the  great  majority  of 
women :  whether  it  develops,  or  how  it  develops,  depends 
upon  the  individual  peculiarities  of  each  case.  Hereditary 
taint  plays  a  very  considerable  part  in  the  development  of 


HYSTERIA.  159 

this  disorder,  mothers  in  verj'  many  instances  transmit- 
ting such  weaknesses  to  their  daughters.  When  there  is 
insanity  in  a  family,  it  also  predisposes  the  female  mem- 
bers to  hysteria,  as  will  also  any  nervous  disease  in  the 
mother. 

Age  is  a  predisposing  cause,  by  far  the  largest  propor- 
tion of  cases  occurring  from  the  accession  to  the  cessation 
of  menstrual  life,  at  both  of  which  periods  its  attacks  are 
much  more  severe  than  at  any  other  time.  Precocious  de- 
velopment of  the  intellect  in  children,  and  allowing  them 
to  mix  too  much  in  the  society  of  their  elders,  taking  them 
to  theatrical  representations,  balls,  parties,  etc.,  thus  un- 
duly stimulating  and  exciting  their  nervous  systems  at  an 
early  period,  exaggerate  their  sensibility  and  make  their 
constitutions  fertile  soil  for  the  development  and  growth 
of  the  seeds  of  hysterical  disorder. 

Climate  plays  no  inconsiderable  part  in  the  development 
of  hysteria,  which,  according  to  many  writers,  is  most 
common  in  extreme  northern  and  southern  latitudes,  and 
especially  in  those  countries  where  women  menstruate  at 
a  very  early  age.  In  large  cities  hysteria  is  much  more 
eommon  than  in  the  country. 

Sedentary  occupations,  improper  diet,  impure  air,  lack 
of  sufficient  bodily  exercise,  constant  brooding  over  relig- 
ious subjects,  and  any  other  circumstances  which  tend  to 
lower  the  tone  of  the  nervous  system,  may  be  ranked 
among  the  exciting  causes  of  hysteria. 

Irritations  of  the  genital  apparatus,  especially  a  perver- 
sion of  the  sexual  functions,  are  also  fruitful  sources  of 
this  disorder.  The  victims  of  sexual  perverts,  either  male 
or  female,  often  suffer  from  very  severe  attacks  of  hys- 
teria. 

Hysteria  is  most  common  in  young  women  and  girls, 


160  FUNCTIONAL    NERVOUS    DISORDERS. 

but  is  not  by  any  means  confined  to  them,  as  we  find  it  in 
women  of  forty  or  fifty,  and  rarely  in  young  men  and  boys. 
In  all  of  these  patients  the  health  is  in  a  poor  condition;, 
the  circulation  is  weak,  the  tone  of  the  nervous  system  is 
lowered  and  unstrung,  and  a  great  variety  of  morbid  sen- 
sations are  present.  The  blood  being  impoverished,  the 
brain  suffers  from  anaemia,  and  irresolution  and  weakness 
take  the  place  of  self-confidence  and  mental  strength. 
These  patients  are  nervous  and  excitable  and  are  liable  to 
sudden  disturbances  of  the  emotions  without  apparent 
cause. 

Much  of  the  illness  prevalent  is  factitious ;  people  who 
are  not  compelled  to  work  hard  for  a  living  having  time^ 
to  indulge  their  morbid  fancies.  Many  of  the  poor  have 
no  time  to  consider  their  sensations,  but  must  work  on  ac- 
tively in  spite  of  weariness  and  fatigue.  Much  supposed 
muscular  weakness  or  weariness  is  in  reality  mental. 
The  hunter,  tired  after  a  long  and  unsuccessful  chase,  sud- 
denly discovers  game  in  the  distance;  fatigue  and  ex- 
havistion  immediately  vanish,  and  miles  are  again  covered 
by  him  with  pleasure  and  a  sensation  of  lightness,  the 
mind  having  overcome  the  body. 

The  view  held  by  Dr.  Bristowe  with  respect  to  hysteria 
and  other  functional  nervous  diseases  and  their  mutual 
relationship  was  that  there  are  many  functional  diseases 
of  the  nervous  system,  among  which  may  be  included 
many  forms  of  insanity,  the  different  classes  of  epilepsy, 
chorea,  migraine,  neuralgia,  and  hysteria.  All  of  these 
are  characterized  by  groups  of  symptoms  referable  to  ex- 
citement, depression,  or  aberration  of  the  nervous  func- 
tions, and  mainly  those  of  the  nervous  centres.  They  are 
severally  distinguished  clinically  by  the  association  of 
definite  groups  of    symptoms,   determined  either  by  the 


HYSTERIA.  -  161 

particular  part  of  the  nervous  system  affected,  by  the  spe- 
cial kind  of  affection  which  takes  place  therein,  or  by  the 
order  and  mutual  relation  of  events.  Thej"  are  regarded 
as  specific  diseases,  because  experience  teaches  us  that 
such  groups  of  symptoms  are  so  commonly  observed  under 
particular  conditions  as  to  show  that  specific  causes  must 
underlie  them  and  determine  their  occurrence.  But  the 
causes  of  the  affections  are  for  the  most  part  closely  related 
to  one  another,  if  not  identical;  the  individual  sj^mptoms 
which  by  their  modes  of  aggregation  constitute  the  sev- 
eral diseases  as  we  know  them  are  common  in  a  greater  or 
less  degree  to  all  of  them.  Many  cases  occur  in  which  it 
is  difficult,  if  not  impossible,  to  determine  satisfactorily  in 
which  category  they  should  be  placed,  and  indeed  there  is 
no  substantial  line  of  demarcation  between  the  diseases. 

Dr.  Bristowe  further  holds  that  hysteria  represents  an 
unstable  condition  of  the  nervous  functions,  that  is  inde- 
pendent of  any  organic  change  in  the  nervous  system,  in 
which,  at  one  time  or  another,  one  or  more  of  its  part 
may  be  temporarily  affected  in  one  of  various  ways. 
There  is,  as  a  rule,  little  difficulty  in  diagnosis,  owing 
partly  to  the  conditions  under  which  the  symptoms  of  the 
disease  arise,  partly  to  the  emotional  state  which  is  usu- 
ally present,  and  partly  to  peculiarities  in  the  symptoms 
themselves. 

Among  the  sensory  disturbances  which  occur  in  hys- 
teria are  ansesthesia,  hypersesthesia,  and  neuralgia. 
Sometimes  the  disturbance  is  local,  at  other  times  quite 
general.  The  ansesthesia  is  most  frequent  on  the  left  side, 
and  may  be  coincident  with  analgesia.  Hem i ansesthesia, 
occurring  with  contracture,  is  frequently  connected  with 
one-sided  ovarian  pain.  The  ansesthesia  is  usually  con- 
fined to  the  integument,  but  when  it  is  very  profound,  the 
11 


162  FUNCTIONAL    NERVOUS    DISORDERS. 

muscular  tissue  and  mucous  membranes  become  involved, 
thus  causing  loss  of  taste  and  smell.  Hearing  and  sight 
may  also  become  deficient  when  there  is  ansesthesia  of 
the  retina. 

Hypersesthesia  may  be  limited  to  the  skin  of  the  hands 
and  feet  or  the  scalp;  it  may  also  occur  in  patches  over 
the  front  of  the  chest  and  abdomen.  Hypersesthesia  of  the 
joints  is  noted  under  the  head  of  joint  neuroses.  These 
pains  in  the  joints  are  sometimes  accompanied  by  oedema 
and  swelling  of  the  tissues,  thus  simulating  rheumatic  in- 
flammation. When  the  special  senses  are  involved,  the 
eye  is  extremel}''  sensitive  to  light  and  hearing  is  markedly 
exaggerated,  so  that  the  slightest  sound,  such  as  the  rus- 
tling of  a  newspaper  is  greatly  magnified,  the  patient  im- 
agining that  the  paper  is  being  violentl}'  torn  to  pieces. 
The  ticking  of  a  clock  may  be  extremely  annoying  from 
its  apparent  loudness,  and  even  the  ticking  of  a  watch 
maj^  be  distressing.  Patients  with  hypersesthesia  of  the 
sense  of  hearing  are  much  annoyed  by  the  fact  of  a  person 
walking  behind  them;  the  footfall  seems  to  them  to  be 
very  noisy,  and  they  imagine  that  they  are  being  pursued 
and  that  the  person  following  them  is  about  to  rush  upon 
them  with  great  force.  This  condition  of  nervousness  is 
apt  to  be  produced  by  the  excessive  use  of  hot  baths  and 
improper  feeding. 

Hysterical  neuralgias  which  are  accompanied  by  other 
signs  of  hysteria  undergo  rapid  modifications  as  regards 
their  severity  and  location.  After  much  excitement,  or 
after  convulsions,  these  neuralgias  may  occur  along  the 
course  of  certain  nerves,  most  frequently  in  the  temporal, 
frontal,  occipital,  or  auricular  regions.  Hemicrania  of 
the  left  side  is  a  very  common  occurrence  in  hysteria. 
Neuralgias  may  also  be  met  with  in  other  situations. 


HTSTEEIA.  163 

Enteralgia  and  cardialgia  are  frequently  observed,  but 
the  most  usual  seat  of  pain  in  these  cases  is  the  ovaries. 
The  ovary  may,  or  may  not,  be  enlarged.  It  is  claimed 
by  Charcot  that  pressure  over  the  region  of  the  ovary  will 
moderate  and  often  stop  the  convulsion  of  hystero-epi- 
lepsy.  I  have  found,  however,  that  pressure  increases  the 
severity  of  the  convulsion,  and  has  an  effect  similar  to 
pressure  of  the  ovary  itself,  which,  as  Charcot  has  stated, 
is  often  sufficient  to  induce  the  hystero-epileptic  attack. 
A  case  quoted  in  the  "  Iconographie  de  la  Salpetriere"  has 
seemed  to  me  of  sufficient  interest  to  be  given  somewhat  in 
detail. 

"In  November,  1887,  Gilles  de  la  Tourette  found 
a  young  hysterical  girl  in  a  ward  of  the  Salpetriere. 
Among  the  other  symptoms  of  her  nervous  affection  she 
had  a  spasmodic  contraction  of  the  upper  and  lower  lid 
of  the  left  eye.  She  first  came  for  treatment  on  the  22d  of 
September.  Her  father  had  a  rheumatic  diathesis,  her 
mother  died  of  heart  disease,  and  her  sister  suffers  from 
hysteria.  She  herself  had  measles  in  childhood,  and  at 
seven  years  of  age  Sydenham's  chorea  appeared  and  lasted 
five  years.  At  fifteen  years  she  first  menstruated.  On 
July  1st,  1887,  she  caught  cold,  had  a  sore  throat,  and  felt 
a  stiffness  in  her  neck.  The  next  morning  she  was  speech- 
less and  could  not  swallow.  At  the  end  of  a  week  the 
throat  was  better,  but  her  voice  had  not  returned,  and  in 
addition  she  had  pain  in  her  knee,  and  markedly  in  the 
right  hip.  During  this  trouble  she  had  also  had  three  or 
four  convulsive  attacks.  La  Tourette  found  that  by  pres- 
sing upon  the  eyeballs  she  was  easily  put  into  a  light 
hypnotic  sleep.  In  this  condition  she  was  able  to  speak 
and  was  entirely  free  from  suffering ;  in  a  more  profound 
sleep  the  same  results  were  obtained.  As  the  result  of  one 
of  her  attacks  in  the  month  of  November,  the  left  eye  re- 
mained closed  and  the  patient  fancied  that  the  lid  was 
more  tightly  held  down  as  time  went  on.     She  had  never 


164  FUNCTIONAL   NEKVOUS    DISOKDERS. 

seen  any  one  suffering  from  blepharospasm.  Her  condi- 
tion on  the  27th  of  November  is  as  follows : 

"  She  is  still  voiceless,  suffers  pain  in  the  left  hip,  and  her 
left  eye  is  still  affected.  She  can  feel  cold  and  the  prick 
of  a  pin  and  can  recognize  touch  all  over  the  right  side  of 
the  body,  with  diminution  in  sensitiveness  in  the  right 
hand  extending  four  fingers'  breadth  above  the  wrist. 
The  left  side  is  less  sensitive  to  touch  and  cold  than  the 
right.  There  is  a  zone  of  analgesia  and  ansesthesia  ex- 
tending the  whole  length  of  the  left  arm.  As  to  the  left 
leg  it  is  a  little  less  sensitive  than  the  right.  The  left 
half  of  the  scalp  is  anaesthetic;  pressure  upon  the  left 
ovary  produces  a  spasm.  Hearing  is  less  acute  on  the 
left  side;  the  left  eye  is  amaurotic,  there  is  nothing  abnor 
mal  in  the  fundus,  and  the  pupil  reacts  to  light.  In  the 
right  eye  the  visual  field  is  narrowed  (|f ) ,  but  there  is 
no  dyschromatopsy.  Upon  applying  Esmarch's  band  to 
the  wrist  the  hand  becomes  flexed ;  if  suddenly  stretched, 
the  arms  remain  in  extension.  No  amount  of  personal 
effort  avails  to  open  the  left  eye,  and  quite  a  resistance  is 
perceptible  upon  forcible  lifting  of  the  lid.  Touching  the 
cornea  causes  lacrymation,  but  no  feeling  of  pain.  Hyp- 
notic suggestion  was  begun  upon  the  37th  of  November, 
and  about  the  first  of  December  the  patient's  voice  returns 
and  her  eyelid  opens,  but  the  eye  is  still  very  weak. 
After  a  few  hours'  interval  sight  is  completely  lost  in  that 
eye;  hypnotic  suggestions  are  made  every  morning. 

"The  hysterical  attacks  continued  until  June,  1888,  but 
in  December  of  that  same  year  when  she  left  the  hospital 
she  was  not  entirely  cured." 

Richer  has  noticed  a  number  of  cases  similar  to  the  one 
described.  The  blepharospasm  is  at  times  clonic,  and 
again  tonic  in  nature;  a  third  variety  is  called  pseudo- 
paralytic. Amaurosis,  complete  or  incomplete,  always 
exists  in  hysterical  blepharospasm.  In  almost  all  cases  of 
hysteria  there  is  present  an  exaggeration  of  motor  excita- 


HYSTERIA.  165 

bility  which  varies  in  degree  from  quick,  precipitate  move- 
ments to  contractions  of  a  single  muscle  or  an  entire 
group,  and  in  some  cases  it  may  even  pass  into  convul- 
sions. Strabismus  (convergent  or  divergent),  with  spasms 
of  the  optic  muscles,  and  spasmodic  twitchings  and  con- 
tractions of  the  muscles  of  the  face  are  manifestations 
which  we  find  in  hysterical  patients  in  the  region  of  the 
head. 

Hysterical  aphonia  in  emotional  young  girls  is  at  times 
associated  with  hysterical  squint.  The  French  writers 
have  especially  noted  the  narrowing  of  the  palpebral  fis- 
sure (hysterical  blepharospasm) ,  with  contraction  or  twitch- 
ing of  the  muscles  of  the  same  side  of  the  face  accompany- 
ing the  condition;  hysterical  anorexia,  vomiting  and  even 
convulsions  may  also  be  present.  The  same  side  of  the 
body  is  usually  the  seat  of  complete  ansesthesia;  not  only 
feeling  but  taste  and  smell  are  deficient,  and  the  percep- 
tion of  color  in  the  corresponding  eye  is  imperfect  or  abol- 
ished. The  ovarian  region,  however,  is  sensitive  to  pres- 
sure. General  chorea,  similar  to  chorea  gravidarum,  is 
also  in  some  cases  an  additional  source  of  distress. 

Occasionally  the  hemi  anaesthesia  is  replaced  by  hyper- 
SBSthesia,  or  there  is,  while  the  patient  is  under  treatment, 
a  partial  or  temporary  transference  of  the  condition  to  the 
other  side. 

In  the  sterno-cleido-mastoid,  the  trapezius,  and  other 
muscles  of  the  neck,  also  in  the  larynx,  pharynx,  and 
oesophagus,  spasm  is  often  developed  in  a  rapid  and  severe 
manner.  Sometimes  the  muscles  of  deglutition  are  inter- 
fered with,  causing  severe  sensations  of  choking. 

Hysterical  dyspnoea  has  been  known  to  be  so  severe  that 
tracheotomy  has  had  to  be  resorted  to  in  order  to  afford 
relief.     This  functional  affection  of  the  larynx  is  of  an 


166  FUNCTIONAL   NEKVOUS    DISORDERS. 

asthmatic  character,  and  comes  on  suddenly  without  rise 
of  temperature ;  it  is  often  accompanied  by  cough. 

Among  the  common  forms  of  hysterical  manifestations 
in  the  region  of  the  neck  and  chest  are  hysterical  laughter, 
shouting,  weeping,  yawning,  cough,  and  asthma. 

In  the  abdominal  region  the  hysterical  phenomena  ob- 
served are  borborygmus,  hiccough,  hysterical  eructations, 
regurgitation  of  food,  vomiting,  and  spasmodic  affections 
of  the  geni to-urinary  apparatus. 

The  attitude  and  walk  in  hysterical  hemiplegia  is  de- 
scribed by  Gilles  de  la  Tourette  as  follows :  "  After  taking 
a  few  steps  the  patient  whose  left  side  is  supposed  to  be 
affected  rests  his  body  on  his  right  foot,  which  is  thrown 
a  little  forward.  All  tonicity  has  left  the  muscles  of  the 
left  leg,  and  they  are  partly  atrophied ;  the  leg  acts  accord- 
ing to  the  laws  of  weight  and  with  the  thigh  forms  an 
obtuse  angle,  strongly  limiting  the  movement  of  the  knee 
ligaments.  The  left  foot  is  placed  in  the  equino-varus  po- 
sition, the  heel  turned  outward,  and  the  point  resting  on 
the  floor  on  the  dorsal  side  of  the  first  three  toes.  It  is 
perfectly  inert,  and  when  the  patient  is  walking  is  dragged 
after  the  other  foot,  all  progress  being  confined  to  the  right 
side." 

Todd  in  his  clinical  lectures  says :  "  I  particularly 
wish  to  call  j^our  attention  to  the  special  character  of  the 
movement  of  the  paralyzed  leg  when  the  patient  walks ;  in 
my  opinion,  it  is  characteristic  of  the  hysterical  affection. 
If  you  watch  a  person  suffering  from  an  ordinary  hemi- 
plegia, the  result  of  a  cerebral  organic  lesion,  you  will  no- 
tice that  in  walking  he  has  a  peculiar  way  of  carrying  the 
paralyzed  limb :  the  healthy  side  of  the  trunk  is  first  car- 
ried forward  and  supports  the  weight  of  the  body ;  then 
by  a  movement  of  circumduction  the  paralyzed  limb  is 


HYSTEEIA.  167 

swung  forward,  causing  the  foot  to  describe  the  arc  of  a 
circle.  The  hysterical  patient,  on  the  contrary,  drags  the 
affected  leg  as  if  it  were  an  inanimate  object ;  there  is  no 
movement  of  circumduction,  and  no  efiort  is  made  to  lift 
the  foot,  which  simply  drags  upon  the  floor." 

This  absolute  paralysis  of  the  limb  is  characteristic  of 
hysteria,  and  its  presence  will  be  of  great  assistance  in 
reaching  a  diagnosis,  should  the  hysterical  stigmata  be 
absent. 

In  speaking  of  hysterical  contractures  Dr.  S.  Weir  Mit- 
chell says:  "We  do  not  know  what  hysteria  is.  So  far 
death  has  destroyed  whatever  evidence  life  might  have 
offered  as  to  its  existence  as  an  obvious  thing  capable  of 
visual  demonstration,  and  still  we  are  apt  sometimes  with 
too  much  confidence  to  refer  back  its  demonstration  to  this 
or  that  centre.  Thus  it  has  been  taken  for  granted  that 
hysterical  contracture  is  due  to  disorder  somewhere  pres- 
ent in  such  columns  of  the  cord  as  are  usually  diseased  in 
spastic  paralysis.  The  chief  basis  upon  which  this  opinion 
rests  is  this :  Cases  of  long-continued  contracture  have 
been  seen  to  end  in  sclerotic  alteration  of  the  lateral  col- 
umns of  the  spinal  cord.  The  inference  is  that  the  pre- 
cedent functional  states  were  also  due  to  the  less  visible 
hysterical  conditions  of  the  columns.  (Soc.  med.  des 
Hopitaux,  Vol.  CXI.,  2d  series,  p.  24,  Charcot.)  More- 
over, it  has  been  taken  for  granted  that  the  state  of  con- 
tracture is  analogous  to  the  condition  we  find  present  in 
muscles  rendered  overresponsive  by  lateral  sclerosis.  I 
am  not  at  all  sure  that  these  inferences  are  safe,  or  even 
that  contracture  is  of  a  certainty  due  to  spinal  centres  at 
all.  It  is  quite  possibly  purely  local  and  muscular  as  to 
origin,  and  indeed  there  are  reasons  why  it  is  extremely 
difficult  to  consider  it  as  of  spinal  birth,  or  in  any  way 


168  FIJlfCTIOXAL    XERVOUS    DISORDERS. 

analogous  to  the  state  of  excitability  seen  in  disease  of  the 
lateral  columns.  I  have  become  quite  assured  that  there 
are  two  forms  of  hysterical  contracture — one  apt  to  be  local 
and  limited,  and  not  followed  by  organic  muscular  changes ; 
the  other  apt  to  affect  two  or  more  limbs,  and  almost  every 
muscle,  even  of  the  trunk,  and  prone  to  result  in  the  mus- 
cular and  areolar  tissue  changes  already  described.  I 
think  it  curious  that  while  the  earlier  stage  of  general  con- 
tracture is  most  difficult  to  cure,  when  the  disease  has 
caused  organic  changes  and  is  in  its  second  stage  it  is  far 
less  hard  to  deal  with.  Perhaps  this  may  be  due  in  part 
to  the  disappearance  of  active  hysteria.  Indeed  it  is  often 
true  that  in  certain  old  examples  of  contracture,  the  sj^mp- 
tom  contracture  exists  no  longer,  and  we  have  to  deal 
alone  with  the  mischief  of  originallj^  shortened  muscles, 
altered  joints,  and  sclerematous  changes  in  the  intermus- 
cular space.  The  hysteria  is  lost  with  years ;  the  spasm 
lessens  or  ceases;  the  consequences  and  additions  remain." 

The  causation  of  this  affection  is  to  a  degree  frequently 
emotional.  It  comes  on  sometimes  abruptly",  and  its  dura- 
tion may  be  short,  or  for  the  rest  of  the  patient's  life.  It 
may  affect  all  or  several  muscles,  and  all  the  extremities 
may  be  involved,  as  represented  in  Fig.  16.  Sometimes 
the  spasm  is  continuous,  again  it  is  intermittent.  Local 
anaesthesia  is  present,  as  a  rule ;  under  ansesthestics,  and 
sometimes  during  sleep  in  the  early  simpler  cases,  there  is 
relaxation.  After  the  muscles  shorten  or  harden,  there  is 
of  course  no  relaxation.     General  contractures  are  rare. 

In  the  treatment  of  this  condition  gradual  extension  by 
instrumental  means  may  be  employed,  such  as  extension 
braces  with  ratchets,  or  an  apparatus  with  weights.  It  is 
extremely  important  that  the  Weir  Mitchell  method  of 
isolation  should  be  resorted  to  early  in  these  cases. 


HYSTERIA. 


169 


A  careful  ophthalmoscopic  examination  should  be  made, 
in  order  to  assist  in  excluding  organic  disease.  Hysteri- 
cal contractures  are  what  we  term  functional,  as  no  or- 
ganic changes  are  found  in  the  spinal  column  as  causa- 
tive factors.  Under  treatment  by  massage,  hydro-  or  elec- 
tro-therapy, and  curative  exercise  as  practised  in  a  Zander 


Fig.  15.— Reflex  or  "  Hysterical "  Contraction  Due  to  Gastric  Irritation. 

institute,  the  affected  parts  often  rapidly  regain  their 
former  condition.  In  some  cases  tendons  will  have  to  be 
cut. 

Hysterical  contractures  of  the  sphincters  of  the  vagina, 
bladder,  and  anus  are  quite  common.  Contractures  of  the 
extremities  (see  Figs.  16  to  21)  often  appear  after  emotional 
excitement  or  convulsions.  Tremblings  are  also  common, 
particularly  of  the  upper  extremities ;  sometimes  the  lower 
extremities  are  also  involved.  When  respiration  is  inter- 
fered with,  there  may  be  severe  manifestations  of  dyspnoea. 


170  FUNCTION"AL    NERVOUS   DISORDERS. 

and  attacks  of  asthma  and  asphyxia  in  lungs  that  are  nor- 
mal are  common  reflex  hysterical  symptoms.  Anorexia 
or  bulimia  is  also  commonly  present.  Epigastric  pulsa- 
tion, tympanitic  distention,  constipation,  belching,  and 
obstinate  vomiting  are  often  seen  in  these  patients.  Men- 
struation is  often  disordered  ;  it  may  be  suppressed,  scanty, 
or  irregular. 

When  there  is  retention  of  urine  from  ansesthesia  of  the 
vesical  mucous  membrane  in  paralysis  of  the  bladder, 
careful  catheterization  must  be  employed  for  a  consider- 
able length  of  time ;  suppression  of  the  urinary  flow  (anu- 
ria) or  morbidly  diminished  urinary  secretion  (oliguria) 
is  often  noted. 

The  following  cases  I  quote  from  the  "  Iconographie  de 
la  Salpetriere, "  as  I  consider  them  of  value  in  the  descrip- 
tion of  hysterical  manifestations: 

"  Paul  Richer  calls  attention  to  a  case  of  hysterical  con- 
tracture of  the  right  leg  which  deserves  mention  because 
of  the  unusual  position  of  the  limb,  and  because  of  its  re- 
sistance to  all  treatment,  including  hydrotherapy  and  mag- 
netism. 

"  The  patient,  seen  in  February,  1882,  was  a  young  girl 
of  fifteen  years,  with  no  other  history  than  that  of  an  im- 
petiginous eczema  of  the  face  and  hands  during  childhood 
(being  covered  with  an  eruption  until  the  age  of  seven;, 
and  frequently  occurring  attacks  of  ophthalmia.  There 
was  no  history  of  nervous  antecedents  in  the  family. 

"  Four  years  previously,  at  the  age  of  eleven,  during  a 
railway  journey,  she  claims  to  have  gone  to  sleep  in  a 
twisted  position,  or  she  may  have  taken  cold.  The  follow- 
ing day  intense  pain  was  felt  in  the  right  hip,  which 
seems  to  have  persisted  for  several  days.  Before  she  left 
her  bed  a  stiffness  of  her  right  leg  was  noticed,  and  a  few 
days  later  the  right  arm  was  affected  in  the  same  way. 
The  position  of  the  arm  was  that  of  flexion,  the  fingers 


HYSTERIA.  171 

bent  inward,  the  hand  bent  upon  the  forearm,  and  the 
forearm  upon  the  arm  in  inward  rotation  and  adduction 
in  such  a  manner  that  it  was  placed  transversely  behind 
the  back. 

"  The  lower  limb  was  in  a  position  of  extension,  the  thigh 
extended  upon  the  leg  and  pelvis,  the  foot  in  extension. 
Eighteen  months  later  the  condition  gradually  improved, 
and  in  a  few  weeks  showed  no  trace  of  stiffness.  The  leg, 
however,  remained  in  a  state  of  contracture,  so  that  the 
patient  was  unable  to  sit  down ;  she  was  obliged  to  eat  in 
a  standing  posture,  and  in  walking  trod  upon  the  heel,  the 
toes  being  elevated.  Any  effort  to  lower  the  toes  or  to 
flex  the  leg  upon  the  thigh  increased  the  rigidity  of  the 
muscles.  The  right  leg  was  by  measurement  found  to  be 
4.5  cm.  smaller  than  the  left,  the  right  thigh  1.5  cm. 
smaller  than  the  other.  During  sleep  the  contracture  en- 
tirely disappeared,  but  returned  at  once  upon  waking,  and 
even  when  sleep  was  light  or  disturbed.  Dr.  Sayre,  of 
New  York,  endeavored  to  overcome  the  condition  by 
forced  flexion ;  a  plaster  dressing  was  tried,  but  as  soon 
as  it  was  removed  the  contracture  reappeared.  The  ma- 
nipulations and  dressings  caused  intense  pain." 

A  case  under  Delprat's  charge  in  Amsterdam  is  inter- 
esting. 

"A  young  girl  of  seventeen,  previously  strong,  and 
with  no  personal  history  of  neurosis,  but  belonging  to  a 
very  nervous  family,  came  in  February,  1891,  for  treat- 
ment for  her  face,  which  was  affected  with  bilateral  con- 
tracture. The  trouble  dated  from  the  previous  August, 
when  it  started  with  toothache  of  the  left  upper  incisors. 
After  a  month's  duration  of  the  pain,  the  patient  noticed 
that  the  left  side  of  her  face  was  at  times  subject  to  con- 
tractures. These  were  at  first  temporary,  lasting  from 
one-half  hour  to  three  hours  and  a  half,  and  occurred  sev- 
eral times  in  the  twenty-four  hours.  After  a  month's 
duration  they  spread  to  the  right  side  of  the  face.     A  de- 


172  FUNCTIONAL   NERVOUS    DISORDERS. 

cayed  incisor  was  taken  out,  but  the  face  remained  in  th© 
same  condition. 

"  The  patient  is  ansemic,  too  tall  for  her  age,  thin,  and 
has  a  laughing,  bizarre  expression.  The  labial  commis- 
sure is  elevated  on  the  right  side,  and  lov^ered  on  the  left, 
the  nasal  groove  being  more  marked  on  the  right  side. 
At  first  sight  one  is  forcibly  reminded  of  facial  hemi- 
plegia. The  right  eye  looks  smaller  than  the  left,  which 
is  due  to  a  slight  contraction  of  the  right  palpebral  orbi- 
cularis. Upon  a  careful  examination  it  is  seen  that  the 
contraction  is  also  quite  evident  on  the  left  side.  In 
breathing  the  cheek  is  not  flabbj'  as  if  inert,  the  air  escap- 
ing more  easily  on  the  right  side.  In  opening  the  mouth, 
the  opening  is  larger  on  the  right  side  than  on  the  left ; 
the  tongue  is  protruded  without  deviation,  and  is  freely 
movable.  When  the  left  side  is  covered,  the  expression 
on  the  other  appears  to  be  that  of  a  laughing  disdain. 
The  expression  of  the  left  side  is  sad  and  dull.  If  the 
mouth  be  energetically  rubbed,  the  contraction  disappears 
and  the  expression  becomes  normal.  After  a  few  seconds 
of  rest,  a  twitching  begins  in  the  levator  labii  superioris 
aleeque  nasi,  and  in  the  zygomaticus  major  of  the  right 
side.  After  each  tremor  the  degree  of  contraction  in- 
creases until  it  becomes  fixed.  At  the  same  time  contrac- 
tions are  seen  in  the  levator  menti  of  the  left  side,  and  the 
chin  is  somewhat  elevated.  The  left  labial  commissure  is 
a  trifie  lowered,  the  upper  lip  becomes  stiff,  the  ala  nasi  is 
depressed,  and  the  lower  lip  protrudes  slightly  beyond  the 
upper.  All  this  happens  in  about  two  minutes'  time. 
Even  in  sleep  the  contracture  persists.  The  decayed  teeth 
seem  to  have  been  the  cause  of  the  trouble  in  this  case. 
The  patient  is  highly  hysterical ;  she  has  a  hemi-f arado- 
cutaneous  anaesthesia  on  the  left  side  (face,  arm,  and  leg). 
Upon  the  left  side  she  feels  the  electric  brush  only  when 
it  is  applied  with  more  force  than  on  the  right. 

"  In  the  treatment  of  this  patient  suggestion  was  used 
without  hypnotic  sleep.  Her  willingness  to  aid  in  the 
treatment  was  of  great  assistance.     Suggestion  was  con- 


HYSTERIA.  173 

tinned  for  about  eight  weeks,  and  four  months  later  there 
was  an  apparently  perfect  cure." 

Paul  Richer  thus  describes  the  diathesis  of  hysterical 
contracture:  "The  victim  of  this  trouble  presents  no 
objective  sign;  he  preserves  freedom  of  movement,  the 
manifestations  of  his  trouble  being  always  brought  about 
by  the  manipulations  of  the  physician  or  b}'  some  chance 
occurrence.  This  condition  of  the  neuro-muscular  sys- 
tem partakes  of  paralysis  in  that  it  usually  coincides  with 
a  weakness  of  motility,  and  of  contracture  in  that  the 
slightest  excitement  will  bring  it  on  or  cause  it  to  dis- 
appear. This  diathesis  is  found  outside  of  hysteria.  It 
has  been  called  '  latent  contracture. '  Its  principal  points 
are: 

"1.  Exaggeration  of  the  tendon  reflexes.  This  is  con- 
stant but  variable  in  degree. 

"  2.  Epileptoid  tremblings.  This  may  occur,  but  very 
rarely. 

"  3.  The  muscles  react  to  electricity,  but  in  a  modified 
degree. 

"  A.  When  the  interruptions  of  the  electrical  current  are 
rapid,  the  muscles  are  tetanized  as  in  health,  but  in  hys- 
teria the  muscles  acted  upon  are  not  the  only  ones  con- 
tracted. 

"  B.  If  the  interruptions  are  slow ,  the  muscular  twitch- 
ings  are  at  first  slow  and  distinct,  but  finally  become 
continuous. 

"  C.  There  are  certain  irregularities  in  the  muscular 
twitchings : 

"  a.  Myographic  readings  show  a  lengthening  of  the  de- 
scending curve. 

"  b.  At  times  a  single  electric  shock  will  bring  on  a  per- 


174  FUlSrCTIONAL   ISTERVOUS    DISORDERS. 

manent  contraction,  in  which  case  the  descending  curve  is 
incomplete,  and  the  muscle  remains  in  a  state  of  contrac- 
ture. 

"  c.  As  a  rule  several  shocks  are  needed  to  give  this  per- 
manent contracture. 

"4.   Contractures  are  brought  on  by: 

"  Deep  muscular  massage. 

"  A  succession  of  raps  upon  the  tendon. 

"  Stretching  and  flexion  of  the  limbs. 

"  Injury  to  a  nerve. 

"  Application  of  a  vibrating  tuning-fork. 

"  Faradization  of  the  muscles  or  nerves. 

"  Magnetism. 

"  Superficial  excitement  of  the  skin  by  light  pressure. 

"  Suggestion  while  the  patient  is  awake. 

"  These  various  methods  are  not  of  equal  efficacy." 

Sollier  and  Malapert  speak  in  the  following  manner  of 
voluntary  contraction  in  a  hysterical  patient : 

"Contraction,  whether  organic  or  the  result  of  experi- 
mentation, may  be  defined  as  a  pathological  state  of  the 
muscle  characterized  by  an.  involuntary  and  continuous 
rigidity.  A  man  thirty-five  j^ears  old,  an  acrobat  by  pro- 
fession, has  suffered  a  slight  muscular  rupture  of  one  of 
the  adductors  of  the  thigh.  His  father  was  not  of  a  ner- 
vous temperament;  the  mother  suffered  from  migraine 
and  an  aunt  was  somnambulistic.  The  patient  himself 
has  met  with  several  professional  accidents;  at  the  age  of 
sixteen  he  was  operated  upon  for  a  tuberculous  testicle. 

"  His  health  is  good,  although  he  is  a  heavy  drinker  and 
suffers  from  alcoholic  tremors ;  strange  to  say,  he  has  but 
little  strength  in  his  arms.  The  peculiarity  which  he 
possesses  is  that  he  can  at  will  induce  a  contracted  con- 
dition of  certain  muscles.     He  stretches  his  arm  horizon- 


HYSTERIA.  175 

tally,  the  anterior  surface  turned  upward  with  his  five 
fingers  in  apposition  at  the  tips.  While  he  watches  his 
arm  with  great  attention,  the  flexors  forcibly  contract, 
and  are  followed  by  the  supinator,  brachialis  anticus,  and 
finally  the  posterior  muscles.  The  forearm  meanwhile  is 
affected  with  increasingl}^  severe  spasmodic  twitchings. 
Then  suddenly  the  hand  is  placed  in  forced  pronation,  and 
then  it  and  the  forearm  are  placed  in  forced  extension. 
The  arm  drops  alongside  of  the  body  at  an  angle  of  20° ; 
the  whole  proceeding  has  taken  from  ten  to  fifteen  seconds. 
In  the  condition  described  the  muscles  of  the  hand  and 
those  of  the  forearm  are  absolutely  contracted,  the  contrac- 
tion diminishing  from  the  distal  extremity  to  the  origin 
of  the  limb.  The  extended  fingers  cannot  be  closed.  The 
wrist  can  be  moved  a  little,  the  elbow  a  trifle  more  freely, 
and  the  shoulder  still  more  readily.  The  flexors  of  the 
fingers  are  hard  and  contracted,  but  less  so  than  the  exten- 
sors. This  state  of  contraction  may  last  for  more  than 
an  hour,  and  can  be  brought  on  at  will,  the  patient  feeling 
no  cramps  at  all.  He  can  act  upon  the  abdominal  muscles 
in  the  same  way.  He  first  contracts  the  recti  abdominis, 
and  as  the  thorax  enlarges  the  intestines  seem  displaced 
upward.  The  abdomen  is  then  suddenly  depressed  and 
the  whole  intestinal  mass  is  pushed  upward,  all  the  organs 
being  displaced.  It  is  possible  for  the  patient  to  walk,  talk, 
eat  and  drink  in  this  condition,  which  lasts  from  ten  to  fif- 
teen minutes.  In  putting  an  end  to  this  performance  he 
proceeds  slowly,  the  whole  mass  sinking  gradually  into 
position. 

"This  man  is  a  tj^pical  hysteric.  His  pharynx  has 
no  sensibility,  as  is  proved  by  the  power  he  possesses 
of  swallowing  glass;  at  times  he  has  a  globus  in  the 
region  of  the  right  floating  ribs.     He  is  deaf  in  the  left  ear 


176  FUNCTIONAL   NEEVOUS    DISOEDERS. 

and  slightly  so  in  the  right.  His  sense  of  taste  is  much 
impaired." 

In  hysteria  both  circulatory  and  respiratory  symptoms 
or  disorders  are  common.  Pulsations  of  the  abdominal 
aorta,  which,  owing  to  a  stiffness  of  the  abdominal  walls 
from  local  inflammatory  states  are  readily  transmitted  to 
the  palpating  hand,  are  often  in  these  cases  mistaken  for 
aneurism.  Tachycardia,  or  rather  palpitation  and  irregular 
beating  of  the  heart,  are  also  common,  the  rate  of  beating 
sometimes  going  as  high  as  two  hundred  in  the  minute. 
"  In  severe  attacks  of  hysteria,  swelling  of  the  neck  is  of 
frequent  occurrence,  but  it  is  seldom  seen  as  a  permanent 
symptom  between  the  paroxysms.  Richer  has  seen  one 
case  at  the  Salpetriere.  It  is  the  result  of  blood  stasis, 
itself  the  result  of  respiratory  and  muscular  spasm.  The 
stopping  of  respiration  stops  the  call  for  venous  blood  to 
the  thorax  which  is  produced  by  every  respiratory  move- 
ment; the  contracted  muscles  compress  the  veins  of  the 
neck  as  they  enter  the  chest  and  more  or  less  interfere  with 
the  flow  of  blood.  As  the  neck  enlarges  the  tissues  become 
congested,  the  superficial  veins  enlarge  and  bulge  out  under 
the  skin ;  this  congestion  spreads  to  the  face,  the  lips,  the 
eyes,  etc.  These  phenomena  are  at  times  so  striking  that 
they  give  a  special  character  to  hysteria." 

Emile  Boix  gives  a  case  of  blue  hysterical  oedema : 

"  The  patient  is  a  man  of  thirty-five  years.  There  is  a 
history  of  neuralgia  in  some  members  of  the  family.  The 
patient  was  troubled  with  incontinence  of  urine  up  to  the 
age  of  fourteen  years.  He  has  had  three  attacks  of  rheu- 
matism, and  has  twice  had  facial  erysipelas.  There  is  no 
history  of  specific  trouble.  In  August,  1888,  he  had  pain- 
ful cramps  in  the  right  hand,  especially  when  attempting 
to  grasp  any  object ;  then  the  hand  became  cold,  pale,  and 


HYSTERIA.  177 

numb,  so  that  he  was  unable  to  use  it.  On  the  fourth 
morning  after  the  onset  of  the  attack,  the  hand  v,'a.s  enor- 
mously swollen.  He  then  entered  the  hospital,  and  pre- 
sented the  following  symptoms :  His  right  arm  was  par- 
alyzed, the  hand  cedematous,  cold,  and  bluish  in  color, 
stiff,  with  absolute  absence  of  feeling  in  the  fingers.  The 
pharynx  was  also  anaesthetic;  the  eyes  were  normal  and 
there  was  no  other  perceptible  trouble. 

"'  The  patient  was  put  under  the  influence  of  chloroform, 
and  the  hand  turned  pinkish  in  hue ;  its  temperature  was 
higher  than  that  of  the  left  hand.  It  remained  quite  stiff, 
which  was  doubtless  due  to  the  rheumatic  trouble,  as  there 
were  fibrous  bands  present;  sensibility  returned  and  the 
paralysis  and  oedema  disappeared,  all  within  the  twenty- 
four  hours. 

"  On  January  1st,  1890,  the  man  returned  to  the  hospital, 
again  complaining  of  the  swelling  in  his  hand ;  the  thumb 
was  also  involved,  as  well  as  half  of  the  forearm.  In 
March  the  cedema  had  disappeared,  only  to  reappear  in 
August.  In  December  of  the  same  year  the  condition  of 
the  patient  is  as  follows.  He  is  a  tall,  fair  man,  with  blue 
eyes;  his  hair  is  scrupulously  parted  and  his  moustache 
curled ;  his  voice  is  altered ;  in  short  he  has  the  character- 
istic appearance  of  an  hysteric.  The  muscular  develop- 
ment is  only  medium ;  his  right  hand  only  is  affected,  the 
arm  seems  paralyzed,  the  patellar  reflex  is  normal.  On 
his  right  side  he  is  insensible  to  touch,  and  the  sensibility 
to  heat  and  cold  is  much  diminished ;  the  pharynx  is  still 
antesthetic,  this  ansesthesia  being  shared  by  one  half  of 
the  tongue,  the  right  nostril,  conjunctiva,  and  ear.  Taste, 
smell,  and  sight  are  affected  upon  the  right  side.  The 
hand,  especially  upon  the  dorsal  aspect,  is  swollen,  almost 
to  bursting;  its  color  is  still  blue.  The  oedema  is  not 
affected  by  position,  and,  although  it  pits  on  pressure,  the 
swelling  immediately  returns.  The  hand  is  absolutely 
insensible;  it  remains  in  a  flexed  position,  and  when  an 
attempt  is  made  to  move  the  fingers  the  muscles  of  the 
forearm  are  affected  as  in  spinal  epilepsv.  At  times  there 
12 


178  FUNCTIONAL   NEKVOUS    DISOEDEES. 

is  a  rhythmic  tremulousness  of  the  hand.  There  is  exces- 
sive perspiration  of  the  right  axilla. 

"  Three  facts  are  worthy  of  ©special  notice  in  this  case. 

"  1.  The  coloration  of  the  hand  was  changeable,  passing 
from  a  violaceous  blue  to  a  whitish  tinge,  as  in  the  case  of 
oedema  due  to  a  cardio-renal  lesion. 

"  3.  Although  the  oedema  felt  hard,  the  fact  that  it  would 
pit  upon  pressure  made  it  probable  that  it  was  elastic 
oedema. 

"3.  The  temperature  of  the  hand  was  found  to  vary  in 
its  different  parts,  the  variation  at  times  being  as  much 
as  16.4°. 

"  The  suggestion  that  the  effect  of  hypnotism  should  be 
tried  appears  to  have  alarmed  the  patient,  and  to  have 
caused  his  disappearance.  He  was  evidently  averse  to 
having  the  condition  cured,  as  it  obtained  support  for  him 
in  the  hospitals." 

Wallet  gives  this  description  of  hysterical  anorexia. 

"  This  is  found  only  in  young  girls,  usually  between  the 
ages  of  twelve  and  fifteen.  When  present,  it  is  usually 
the  only  symptom  of  hysteria.  Its  persistence  and  the 
rate  at  which  it  increases  unless  promptly  and  energeti- 
callj^  treated  would  lead  one  to  believe  that  it  was  due 
to  a  nervous  degeneration. 

"  It  is  of  indefinite  duration,  and  when  weakly  indulgent 
parents  do  nothing  to  overcome  the  obstinacy  of  the 
patient,  as  sometimes  happens,  death  is  the  result.  The 
weakened  condition  of  the  patient  makes  her  an  easy 
victim  to  disease,  more  especially  tuberculosis.  To  quote 
a  case  in  point : 

"Miss  B.,  seventeen  years  of  age,  was  brought  to  the 
Auteuil  Hydrotherapeutic  Institute  in  a  terribly  emaci- 
ated condition.  All  the  bones  were  plainly  visible,  the 
muscles  were  easily  felt,  the  skin  was  dull  and  lifeless, 
cold  and  clammy.     Her  eyes  were  sunken,  lips  swollen, 


HYSTERIA.  179 

tongue  coated,  and  breath  foul.  The  skin  of  the  legs  was 
blotched  in  appearance;  there  was  slight  oedema  of  the 
feet  and  ankles,  which  pitted  on  pressure.  The  patient 
was  very  constipated,  and  her  menstruation  had  ceased. 
The  visual  field  was  slightly  diminished.  She  was  very 
fond  of  walking,  and  this  exercise  was  allowed  her  on  the 
condition  that  she  would  consent  to  take  her  food.  As 
no  improvement  followed,  long  walks  were  forbidden,  and 
she  was  not  allowed  to  go  bej'^ond  the  boundaries  of  the 
garden;  even  this  limited  amount  of  exercise  had  to  be 
stopped,  the  patient  confined  to  her  room,  and  finally  to 
her  bed.  She  still  contrived  to  get  more  exercise  than 
was  good  for  her,  as  she  had  the  fixed  notion  that  repose 
would  fatten  her,  and  she  thought  that  her  looks  were  im- 
proved by  extreme  thinness.  After  six  weeks'  treatment 
menstruation  reappeared,  and  her  weight  increased  from 
27  to  34  kilos." 

Hysterical  fever,  as  the  result  of  nervous  excitement, 
usually  begins  with  a  chill  which  is  followed  by  the  fever- 
ish symptoms;  these  are  usually  confined  to  the  face  and 
head.  The  patients  easily  become  delirious,  and  may  have 
tremor  or  convulsions ;  the  mouth  is  dry  and  the  appetite 
impaired.  The  temperature  rises,  and  the  pulse  increases 
from  normal  to  100  or  120  a  minute. 

Under  the  head  of  vascular  secretory  neuroses  may  be 
placed  hysterical  salivation.  It  is  not  common,  but  has 
occasionally  occurred. 

Hysterical  psychoses  manifest  themselves  in  the  lighter 
forms  by  excitability  and  great  sensitiveness  to  matters 
of  minor  moment;  by  sudden  changes  from  sadness  to 
gayety,  or  by  attacks  of  sullenness  and  obstinacy.  In  the 
more  pronounced  forms,  melancholia  or  mania  may  de- 
velop. 

Brissaut  and  Souques  report  the  following  case  of  delir- 
ium of  hysteria. 


180  FUNCTIONAL   XEEVOUS   DISOKDERS. 

■'A  young  girl,  9  years  of  age,  of  nervous  origin,  fell 
upon  her  right  hip,  and  as  a  consequence  had  pain,  swell- 
ing, and  redness  of  the  parts.  The  swelling  subsided, 
but  left  in  its  place  a  psychical  hypersesthesia  which  lasted 
for  ten  years.  It  showed  itself  in  various  ways,  such  as 
vomitings,  swelling  of  the  abdomen,  and  attacks  of  un- 
consciousness. 

"  Through  a  mistake  in  diagnosis  she  was  at  first  treated 
for  coxalgia,  then  for  abscess  with  peritonitis,  and  was  on 
the  point  of  being  treated  by  laparotomy.  It  was  really  a 
case  of  hysterical  simulation,  probably  induced  by  the 
questioning,  explorations,  and  treatment  of  the  physician. 

"  At  the  age  of  thirteen,  injudicious  friends  began  to  tease 
her  about  getting  fat,  and  thus  she  became  impressed  with 
the  desire  to  become  thin.  Her  method  of  attaining  this 
end  was  to  eat  as  little  as  possible  and  to  vomit  all  that 
she  did  eat.  For  some  time  her  wish  to  grow  thin  was 
somewhat  latent,  although  a  fixed  idea,  but  at  the  age  of 
sixteen  the  teasing  became  too  much  for  her  to  bear,  and 
she  absolutely  refused  food.  She  became  alarmingly 
emaciated,  and  was  several  times  at  the  point  of  death. 
In  an  ecstatic  religious  state  she  sought  help  at  Lourdes, 
and  the  first  time  apparently  received  benefit;  the  second 
time,  however,  the  pilgrimage  did  her  no  good,  and  this 
fact  threw  her  into  a  state  of  despondency,  as  she  imagined 
that  she  must  have  fallen  from  grace,  probably  because  of 
unconfessed  sins.  This  despondency  changed  into  a  fixed 
mania.  Under  treatment  she  gained  thirty  kilos  in 
weight  in  three  months'  time.  This  sudden  regaining  of 
fat  is  seen  only  in  hysterical  patients." 

In  somnambulism  of  hysterical  origin,  as  in  the  ordinary 
type  of  somnambulism,  the  supervision  of  the  mind  over 
the  organs  of  special  sense  is  for  the  time  being  sus- 
pended. Some  consciousness  is  present,  but  it  is  not  usually 
of  sufficient  intensity  to  leave  much  if  any  impression  on 
the  mind  when  the  patient  is  awakened. 

There  is  generally  present  in  hysteria  more  or  less  intense 


HYSTERIA.  181 

inclination  to  sleep,  which  may  go  on  to  lethargy,  a  con- 
dition which  may  last  several  days.  This  has  been  de- 
scribed as  transient  catalepsy.  Several  kinds  of  spas- 
modic manifestations  most  usually  precede  the  state  of 
somnolence.  The  pulse  becomes  small  and  intermittent; 
the  breathing  is  slow  and  in  some  cases  scarcely  to  be 
detected.  The  skin  is  dry  and  cold  ;  the  bladder  loses  the 
power  to  evacuate  its  contents,  rendering  necessary  the  use 
of  the  catheter.  The  bowels  also  lose  their  power  to  act, 
and  may  remain  in  this  condition  for  weeks.  The  most 
powerful  stimulation  is  needed  to  arouse  the  patient  from 
this  state  for  even  a  short  time. 

At  the  termination  of  hysterical  convulsions  there  is  a 
somewhat  similar  condition  of  somnolence,  but  the  fact 
that  it  is  of  short  duration,  and  is  followed  by  alleviation 
of  the  patient's  symptoms,  will  serve  to  distinguish  it 
from  the  state  here  described. 

The  most  unusual  and  severe  form  into  which  this 
hysterical  somnolence  may  pass  is  the  condition  known  as 
hysterical  trance.  The  patient  sees  and  hears,  either  per- 
fectly or  in  part,  what  is  going  on  around  her,  but  is  un- 
able to  move  or  to  call  out. 

There  is  a  condition  known  as  disease  mimicry.  We 
all  remember  our  mothers'  early  warning  that  "  mocking 
is  catching."  From  automatic  conditions  this  is  a  natural 
tendency.  Mimicry  of  normal  and  abnormal  conditions 
exists,  an  example  being  the  suffering  of  sympathetic  labor 
pains  upon  the  part  of  husbands  present  during  the  parturi- 
tion of  their  wives,  or  their  sufferings  from  the  morning 
sickness  of  pregnancy.  Francis  Bacon  speaks  of  this 
morning  vomiting,  and  Dr.  Weir  Mitchell  reports  such  a 
case.  The  treatment  of  hysteria  may  be  divided  into  (1) 
psychical,  (2)  separation  of  the  patient  from  her  friends 


182  FUNCTIONAL   NERVOUS    DISORDERS. 

and  usual  surroundings,  with  such  other  moral  treatment 
as  may  be  deemed  proper,  and  (3)  medical  treatment.  In 
the  last-named,  the  effort  must  be  to  combat  the  anaemia 
present  by  tonics  and  a  large  amount  of  meat  in  the  diet. 
Massage  and  electrical  baths  with  the  static  and  inter- 
rupted current  are  also  useful  adjuncts.  The  moral  treat- 
ment consists  mainly  in  removing  the  patient  from  the 
pernicious  influence  of  relatives  and  friends  who,  although 
meaning  well,  do  harm. 

Functional  diseases  of  the  nervous  system  are  in  the 
great  majority  of  cases  due  to  malassimilation,  as  is  the 
case  with  the  organic  diseases.  In  both  acute  and  chronic 
cases  the  results  obtained  by  treatment  will  depend  upon 
the  care  which  we  bestow  upon  the  digestive  organs.  In 
the  physiological  cure  of  disease  the  state  of  the  digestive 
organs  is  the  all-important  factor;  medicines  may  assist^ 
but  it  is  quite  as  probable  that  they  often  retard  recovery. 


CHAPTER  XX. 

HYSTERO  -  EPILEPSY. 

Hystero-epilepsy,  according  to  Charcot  and  Richer,  is 
only  hysteria  in  the  highest  degree,  and  not  hysteria  com- 
plicated with  other  neuroses.  Although  hysteria  in  the 
male  is  not  an  extremely  rare  occurrence,  still  it  is  so  fre- 
quent among  females  that  it  might  be  said  to  be  the  char- 
acteristic disease  of  that  sex.  I  have  seen  one  case  of 
h3'stero-epilepsy  in  a  lad,  which  came  on  from  a  fall  and  a 
great  fright;  and  there  are  many  physicians  who  have 
seen  cases  where  the  male  patient  imagines,  or  learns  for 
the  first  time,  that  he  has  some  fatal  disease,  or  where, 
after  some  great  physical  or  moral  shock,  he  becomes  as 
hysterical  as  a  woman. 

In  hystero-epilepsy  there  is  the  hysterically  nervous  con- 
stitution combined  with  the  depressing  effects  of  anaemia, 
prolonged  anxiety,  mental  shock  or  excitement,  and  the 
stimulus  of  uterine  and  ovarian  disturbance  starting  up 
the  hysteric  aura.  In  about  all  the  functional  diseases  of 
the  nervous  system  of  women,  the  general  condition  is  the 
same — the  co-ordination  and  harmony  of  the  cerebro-spinal 
and  ganglionic  nervous  systems  are  sadly  out  of  tune.  It 
matters  not  what  puUs  the  patient  down,  whether  it  is  an 
exhausting  menorrhagia  or  great  mental  anxiety,  the  re- 
sult is  the  same,  and  manifests  itself  often  in  these  ex- 
plosions of  weakness. 

183 


184 


FUNCTIONAL   NEKVOUS    DISOKDERS. 


The  hystero-epileptic  attack  according  to  Richer  is  di- 
vided into  four  distinct  periods : 

1.  The  epileptoid  period. 

2.  The  period  of  contortions  and  great  movements. 

3.  The  period  of  emotional  attitudes. 

4.  The  period  of  delirium. 

The  epileptoid  period  has  a  tonic  phase,  a  clonic  phase, 
and  a  phase  of  resolution.  Loss  of  consciousness  was  com- 
plete during  the  entire  epileptoid  period  in  the  following 
cases,  as  is  the  rule,  and  all  the  attacks  were  more  or  less 
complete.     In  speaking  of  the  rarity  of  this  disease,  which 


Fig.  16.— First  or  Epileptoid  Period. 

makes  its  study  more  interesting.  Dr.  S.  Weir  Mitchell 
writes  "  that  in  my  experience,  and  it  has  been  very  great, 
these  terrible  cases  are  rare  in  America  in  any  class  of 
life,  and  most  uncommon  in  the  lower  classes,  among 
which  Charcot  seems  to  have  found  his  worst  and  most 
interesting  cases.  In  this  disorder  there  is,  I  suspect, 
some  difference  between  this  country  and  Europe." 

Dr.  Charles  K.  Mills  says  that  hystero-epilepsy  of  im- 
perfectly developed  or  irregular  type  is  a  not  uncommon 
affection  in  this  country,  but  the  disease  in  its  regular 


HTSTERO-EPILEPSY. 


185 


type  is  comparatively  rare.  Dr.  Allan  McLane  Hamilton 
reports  two  cases.  Hart  and  Barbour  state  that  it  is  rare 
in  Great  Britain.  They  have  seen  one  case  in  which  it  • 
was  present  in  a  modified  form.  Many  physicians  whom 
I  have  met,  both  in  Paris  and  New  York,  seem  to  believe 
that  hystero-epilepsy  is  a  Parisian  disease,  and  rarely,  if 
ever,  met  with  elsewhere.  I  see  no  reason  to  think  that  it 
is  any  less  common  here  than  in  France;  and  it  seems  to 
me  that  physicians  generally  see  these  cases  in  their  later 
stages,  and  after  the  most  severe  portion  of  the  attack  has 


Fig.  17.— First  or  Epileptoid  Period.    Tonic  Contractions. 

passed  away,  and  then  simply  consider  it  as  minor  hysteria, 
and  give  it  no  thought.  In  the  twelve  cases  which  follow, 
and  which  have  occurred  in  my  practice,  I  have  taken 
especial  notice  of  the  uterus  and  the  menstrual  function, 
believing  that  the  ovary  alone  is  not  the  only  pelvic  factor 
in  producing  the  disease ;  in  all  of  them,  as  in  almost  all 
previous  cases  reported,  the  uterus  was  diseased  and 
menstruation  abnormal.  Dr.  Charles  Carroll  Lee,  in  a 
short  and  valuable  article  on  "  The  Relation  of  Peripheral 
Irritation  to  Diseases  of  the  Womb  and  its  Appendages," 


186 


FUNCTIONAL   NERVOUS   DISORDEES. 


advises  general  as  well  as  local  treatment,  "  for  in  all  these 
cases  there  is  feebleness  of  tone,  often  waste  of  tissue  and 
marked  hydrsemia,  and  a  general  tendency  to  nerve  ex- 
haustion." He  also  states  that  "it  is  a  striking  clinical 
fact  that  mal-conditions  of  the  uterus  exercise  far  more 
influence  in  this  direction  than  disease  of  the  tubes  or 
ovaries,  however  pronounced  the  latter  maybe,"  and  "that 
in  neurotic  conditions  ablation  of  the  uterine  appendages 
is  not  only  commonly  useless,  but  often  leaves  the  patient 
worse  than  she  was  before."     Engelmann  says  "the  uterus 


Fig.  18.— First   or   Epileptoid   Period.     Tetanic   Attitude,  Tonic  Phase,  of  the 
Hystero-Epileptic  Attack. 

is  more  liable  to  influence  the  system  and  determine  the 
nerve  reflexes  than  the  ovary."  There  is  nothing  to  show 
that  the  ovarian  pain  may  not  be  symptomatic  of  uterine 
disease,  seeing  that  the  latter  is  present  in  such  a  large 
proportion  of  cases,  and  the  ovaries  and  uterus  are  really, 
so  to  speak,  only  different  parts  of  a  single  organ,  although 
often  treated  as  if  there  were  no  connection  between  them. 

Dr.  Mills  states  as  his  conclusions : 

"  In  reference  to  oophorectomy  for  hystero-epilepsy,  or 


HYSTERO- EPILEPSY. 


187 


any  form  of  grave  hysteria:  (1)  It  is  rarely  justifiable ; 
(2)  it  is  not  justifiable  in  case  of  girls  who  have  not  men- 
struated; (3)  when  disease  of  the  ovaries  can  be  clearly 
made  out  by  local  objective  signs,  it  is  sometimes  justifi- 
able ;  (4)  it  is  justifiable  in  some  cases  with  violent  nymph- 
omania ;  (5)  the  operation  is  frequently  performed  without 
due  consideration,  and  the  statistics  of  the  operation  are 
peculiarly  unreliable." 

Most  hystero-epileptics  are  easily  hypnotized  or  already 
in  a  hypnotic  state,  and  the  arrest  of  the  attack  by  what 
Charcot  calls  ovarian  pressure  is  undoubtedly  in  many  in- 


FiG.  19.— Second  Period.     Contortions.    Arc  of  the  Circle. 


stances  through  hypnotic  suggestion,  as  his  application  of 
the  hand  is  often  very  light  and  there  is  really  no  pressure 
to  speak  of.  The  ovarian  pains  are  without  doubt  in  many 
instances  the  sole  cause  of  the  attack.     Charcot  says : 

"  Sometimes  the  pain  is  very  severe,  and  the  patients 
are  unable  to  support  the  least  touch,  as  the  weight  of  the 
bedclothes,  etc.  .  .  .  Add  to  that  a  certain  degree  of 
swelling  of  the  abdomen,  and  you  have  the  clinical  en- 
semble of  false  peritonitis — the  spurious  peritonitis  of  Eng- 
lish  physicians.  ...    At  other   times,  the    pain   is   not 


188 


FUNCTIO^STAL    NERVOUS    DISORDERS. 


■spontaneously  felt ;  we  are  obliged  to  search  for  it  by  pres- 
sure, and  it  is  found  in  the  ovary,  which  is  tumefied,  and 
often  the  size  of  an  olive  or  small  egg.  At  this  moment 
you  can  provoke  the  pain,  which  reveals  itself  with  specific 
characters.  It  is  not  a  common  pain,  but  a  complex  sen- 
sation accompanied  by  either  the  whole  or  a  part  of  the 
phenomena  of  the  aura  hysterica,  the  same  as  they  produce 
themselves  at  the  approach  of  a  crisis,  and  this  provoked 
sensation  is  recognized  by  the  patients  because  they  have 
felt  it  a  hundred  times.  .   .  ,  We  have  provoked  painful 


Fig.  20.  —Second  Period.    Contortions.    Arc  of  the  Circle  Incomplete. 


radiations  toward  the  epigastrium,  complicated  sometimes 
with  nausea  and  vomiting;  then,  if  the  pressure  is  con- 
tinued, soon  come  palpitations  of  the  heart,  with  extreme 
frequency  of  the  pulse,  and  at  last  it  develops  itself  at  the 
neck  in  the  globus  hystericus.  .  .  .  Certain  cephalic 
troubles  are  evidently  only  the  continuation  of  the  same 
series  of  phenomena.  Such  are  (if  we  speak,  for  example, 
of  compression  of  the  left  ovary)  intense  whistlings  in  the 
left  ear,  which  the  patients  compare  to  the  strident  whistle 
of  a  locomotive ;  a  sensation  of  blows  struck  with  a  ham- 
mer on  the  left  temporal  region ;  and,  finally,  a  blurring 
of  vision,  marked  especially  in  the  left  eye.     The  same 


HYSTERO-EPILEPSY. 


189^ 


phenomena  would  show  themselves  on  the  corresponding 
parts  of  the  right  side  in  case  the  compression  should  be 
made  on  the  right  ovary." 

Authors  have  distinguished  two  principal  forms  of 
hystero-epilepsy.  In  the  first,  hystero-epilepsy  with  dis-- 
tinct  crises,  the  convulsive  accidents  are  of  two  kinds. 
They  show  sometimes  the  paroxysm  of  hysteria,  sometimes, 
the  paroxysm  of  epilepsy,  with  the  characters  which  are 
proper  to  each,  and  always  perfectly  distinct.  In  the 
second,  hystero-epilepsy  tvith  combined  crises,  the  con- 
vulsions in  the  very  same  attack  are  invested  successively 


Fig.  21.— Second  Period.     Contortions.     Variety  of  Arc  of  the  Circle. 


with  the  appearance  of  hj^steria  and  of  epilepsy ;  there  ap- 
pears to  be  a  melange  of  the  two  neuroses. 

It  is  with  this  last  form  that  we  are  especially  concerned 
here,  the  form  that  Louyer-Villermay,  Tissot,  Dubois 
(d' Amiens),  Sandras,  Briquet,  and  Charcot  considered  as 
a  grave  variety  of  hysteria,  in  which  the  convulsions  are 
of  an  epileptic  character,  as  occurs  in  many  other  affec- 
tions of  the  nervous  system,  with  the  property  of  an  ac- 
cessory element,  and  without  changing  anything  of  the 
nature  of   the  primitive  malady    (Charcot).      It  is  the 


190  FUNCTIONAL   NERVOUS    DISOEDERS. 

epileptiform  hysteria  of  Louyer-Villermay,  of  Tissot;  the 
hysteria  with  mixed  attacks  of  Briquet,  and  major  or 
grand  hysteria,  as  it  is  designated  by  M.  Charcot.  .  .  , 
A  parallel  between  Richer's  description  of  hystero-epilepsy 
or  major  hysteria  and  that  which  the  authors  give  of  minor 
hysteria  shows  the  intimate  connection  existing  between 
the  two  forms,  the  minor  hysteria  being  considered  as  an 
attenuation  of  the  major,  in  fact,  the  rudimentary  form. 
The  varieties  of  major  hysteria  are  the  results  of  modifica- 
tions of  the  sj^'mptoms  which  already  exist;  therefore  we 
have  the  epileptoid  attack,  the  contortion  or  demoniacal 
attack,  the  attack  of  ecstasy,  and  the  attack  of  delirium. 

There  are  also  varieties  which  result  from  the  com- 
bination of  phenomena  habitually  foreign  to  the  attack — 
whence  come  the  attacks  of  lethargy,  attacks  of  catalepsy, 
and  attacks  of  somnambulism.  This  first  class  receives 
some  new  light  from  Richer's  studies  on  hypnotism  and 
shows  the  near  relationship  which  exists  between  hypno- 
tism and  major  hysteria. 

To  the  varieties  of  the  major  attack  which  have  just 
been  pointed  out  Richer  has  added  also  the  three  follow- 
ing: Attack  of  syncope,  attack  of  spasm,  attack  of  con- 
tracture. The  attack  of  spasm  belongs  to  the  prodromic 
period,  while  the  attack  of  contracture  is  classed  among 
the  varieties  belonging  to  the  fourth  period. 

Prodromic  Period. — The  attack  of  major  hysteria 
never  comes  as  a  surprise ;  it  is  always  preceded,  as  Richer 
says,  sometimes  during  many  days,  by  a  train  of  phe- 
nomena which  permits  the  invalid  to  foresee  long  before- 
hand the  moment  when  she  will  fall  in  the  attack.  These 
signs  are  many  and  various ;  they  betray  the  disorder  of 
the  whole  system,  and  we  can  say  that  none  of  the  im- 
portant organs  is  exempt. 


H1STER0-EPILEPSY.  191 

Richer  arranges  the  prodromes  under  the  following 
heads : 

1.  Disorders  of  the  mind;  hallucinations. 

2.  Disorders  of  the  organic  functions. 

3.  Disorders  of  motility. 

4.  Disorders  of  sensibility. 

He  says:  "The  mental  troubles  are  the  first  to  appear, 
and  come  on  sometimes  eight  days  before  the  attack.  The 
invalid  herself  is  aware  of  a  change  in  her  mind;  she  is 
incapable  of  working  with  the  diligence  required;  she 
neglects  her  habitual  occupations,  and  has  no  pleasure  in 
her  usual  amusements.  Past  impressions  and  recollec- 
tions, especially  if  painful,  come  crowding  to  her  mind; 
she  has  no  power  to  throw  them  off.  Anj'thing  of  a  dis- 
agreeable nature  affects  her  acutely,  and  the  most  insignif- 
icant trifles  assume  in  her  eyes  an  exaggerated  importance. 
Occasionally  she  falls  into  a  condition  of  profound  melan- 
cholia that  may  reach  a  state  of  complete  despair. 

Those  in  close  attendance  upon  the  patient  can  readily 
foresee  the  impending  attack.  Her  external  appearance 
betrays  the  mental  trouble  by  a  neglect  of  the  niceties  of 
the  toilet  and  even  of  cleanliness ;  the  hair  is  dishevelled ; 
the  face  is  emaciated;  the  patient  is  absorbed  in  never- 
ending  reflections  and  meditations;  she  gazes  fixedlj^  into 
space,  while  now  and  then  the  changing  expression  betrays 
the  presence  of  hallucinations.  These  attacks  of  depres- 
sion or  melancholia  alternate  with  moments  of  foolish 
gayety  the  cause  of  which  is  quite  incomprehensible.  The 
patient  indulges  in  all  manner  of  childishness,  a  mere 
nothing  sufficing  to  send  her  into  fits  of  long-continued 
laughter.  The  emotions  are  at  the  same  time  exalted  or 
perverted.  The  patient  is  anxious,  suspicious,  and  very 
irritable.     She  cannot  bear  the  least  contradiction,  and  no 


192  FUKCTIOKAL   NERVOUS    DISORDERS. 

one,  not  even  her  best  friends,  has  any  influence  over  her. 
She  becomes  subject  to  sudden  spasmodic  attacks  of  af- 
fection or  of  hatred  toward  her  companions.  She  will 
become  either  obstinately  mute  or  exceedingly  confidential. 
Very  frequently  she  will  appear  to  seek  an  occasion  for 
dispute  merely  to  satisfy  a  necessity  for  activity.  She  is 
unable  to  keep  still;  there  is  a  restlessness  in  all  her  limbs, 
and  it  is  not  rare  to  see  her,  in  her  excess  of  energy,  turn 
against  surrounding  objects,  overturning,  breaking  and 
ruining  anything  she  finds  under  her  hands.  This  agi- 
tation, accompanied  by  loud  cries,  gives  her  at  times  a 
dreadful  aspect,  but  she  is  never  so  dangerous  as  are  epi- 
leptics in  their  delirium.  The  impulse  obeyed  by  the  pa- 
tient is  not  an  instinct  of  destruction  to  others,  or  to  her- 
self ;  it  is  an  agitation  that  appears  to  have  no  other  aim 
than  that  of  making  a  noise  and  working  off  a  surplus  of 
activity. 

Richer  still  further  says  that  hallucinations  are  frequent 
in  hystero-epilepsy,  and  they  may  affect  all  the  senses,. 
although  they  are  especially  apt  to  affect  sight  and  hear 
ing.  They  often  occupy  an  important  place  among  the 
prodromes  of  major  hysteria.  The  late  M.  Charcot  held 
that  there  was  a  constant  relation  between  the  seat  of 
hallucination  and  that  of  hemiansesthesia.  The  most 
common  hallucinations  of  sight  are  visions  of  animals: 
black  cats,  gray  or  various-colored  rats,  spiders,  crows, 
vipers,  etc.,  or  of  fabulous  animals.  M.  Charcot  was  the 
first  to  show  that  these  are  not  fixed  visions.  The  animals 
appear  to  run  always  in  a  certain  direction  in  front  of  the 
patient,  either  from  left  to  right  or  the  reverse,  according 
as  the  seat  of  the  hemiansesthesia  is  to  the  left  or  to  the 
right.  The  anaesthetic  side  is  always  the  point  of  depar- 
ture of  the  hallucinations ;  the  phantom  as  a  rule  comes. 


HYSTEEO-EPILEPSY.  193 

from  behind  and  disappears  in  front.  Scintillating  stars 
and  brilliant  balls  of  light  of  different  colors  also  appear 
before  the  patient's  eyes.  Richer  asserts  that  hallucina- 
tions of  hearing  are  no  less  common  than  those  of  sight. 
They  affect  principally  the  ear  of  the  ansesthetic  side.. 
These  hallucinations  may  all  come  on  in  the  daytime,  and. 
torment  the  patients  even  when  they  are  in  the  company 
of  other  people,  but  it  is  at  night  that  they  are  the  most, 
intense.  Then  they  are  not  so  much  a  rapidly  passing- 
vision,  as  a  prolonged  drama  in  which  the  patient  has  her 
role  to  play. 

Nearly  all  of  the  patients  are  troubled  with  a  whistling 
sound  in  the  ears,  especially  in  the  ear  of  the  anassthetic 
side.  They  also  hear  the  rolling  of  wagons,  the  striking 
of  clocks,  music  of  a  band,  the  singing  of  birds,  etc. 
The  night  hallucinations  are  often  erotic  in  character, 
which  shows  that  the  genital  tract  is  largely  involved. 
Extreme  fatigue  follows  a  night  of  hallucinations,  and  is 
evinced  by  drawn  features,  pale  faces,  and  dark  circles 
around  the  eyes.  Hallucinations  occupy  so  important  a 
place  among  the  phenomena  preceding  the  attack  of  hys- 
tero-epilepsy  that  they  sometimes  form  part  of  the  aura 
and  mark  the  beginning  of  a  fit. 

Disorders  of  the  Digestive  Functions. — In  chronologi- 
cal order  the  digestive  disturbances  are  the  first  to  appear 
among  the  prodromes  of  the  attack,  along  with  the  cere- 
bral disorders  of  which  we  have  spoken;  they  usually  pre- 
cede by  some  days  the  painful  phenomena.  They  seem  to 
be  constant.  Either  the  patient  is  without  appetite,  or 
else  the  taste  is  much  perverted.  The  food  eaten  is  often 
immediately  rejected.  Between  meals  nausea  is  some- 
times present,  owing  to  the  spasmodic  contractions  of  the 

diaphragm,  of  the  stomach,  and  of  the  oesophagus.     This 
1.3 


194  FUNCTIONAL    NEEYOUS    DISOEDERS. 

may  result  in  a  prolonged  and  painful  state  of  nausea. 
Spasm  of  the  throat,  that  is  to  say,  hysterical  suffoca- 
tion, may  occur  in  the  pharynx,  in  the  oesophagus,,  and  in 
the  upper  part  of  the  trachea  (Briquet). 

If,  says  Briquet  in  his  "  Traite  de  I'Hysterie,"  we  observe 
attentively  what  takes  place  when  an  hysterical  woman 
experiences  a  moral  emotion,  we  may  easily  grasp  the 
reason  of  this  neurosis.  Out  of  four  hundred  hysterical 
patients  he  has  found  only  thirty  who  had  never  been 
troubled  with  suffocation.  This  spasm  of  the  throat,  so 
common  in  hysteria,  which  maj  be  met  with  during  the 
attacks  as  well  as  in  the  intervals,  is  also  observed  among 
the  prodromes  of  major  hystero-epilepsy,  and  ordinarily 
forms  a  part  of  the  painful  phenomena  of  the  aura  hys- 
terica. Mention  should  be  made  here  of  the  borboryg- 
mus  and  the  tympanites  which  are  present,  and  often 
severe. 

Disorders  of  the  Secretions. —  Ptyalism  in  varying 
degree  is  often  present  at  the  beginning  of  the  attack, 
and  plays  its  part  in  the  production  of  the  foam  which 
comes  to  the  lips  in  the  epileptoid  period.  The  urine  is 
abundant,  clear,  and  colorless  (nervous  urine). 

Disorders  of  Respiration. — The  disorders  of  respira- 
tion, as  a  rule,  consist  in  a  more  or  less  pronounced  sense 
of  oppression.  The  patients  feel  the  need  of  breathing 
more  air.  But  the  spasm  of  the  larj^nx  is  a  part  of  the 
convulsive  phenomena  which  occur  during  the  daj^s  pre- 
ceding the  attack,  and  the  hiccough  and  the  laughter 
belong  to  the  same  category.  H3'sterical  yawnings  also 
occur  at  this  time. 

Disorders  of  Circtdation. — Cardiac  palpitations  hold 
a  prominent  place  among  the  prodromes  of  the  hystero- 
epileptic  attack.     All  patients  complain  of  it.     These  pal- 


HTSTEEO-EPILEPSY.  195 

pitations  are  at  first  infrequent,  but  return  upon  the  slight- 
est occasion,  or  without  any  appreciable  cause.  At  a  later 
period  they  constantly  accompany  the  painful  phenom- 
ena of  the  hysterical  aura.  The  palpitations  are  at 
times  so  intense  as  to  be  felt  all  over  the  chest,  in  the 
neck,  and  even  in  the  temples.  Vasomotor  complications 
are  not  uncommon.  Rosenthal  cites  an  interesting  case,  in 
which  the  precursor  of  the  attack  was  a  feeling  of  cold, 
with  discoloration  of  the  hand  and  fingertips.  In  another 
case,  resembling  Rosenthal's,  the  patient's  arms  grew 
colder  and  bloodless,  and  were  insensible  to  the  pricks  of  a 
pin.     The  patient  was  at  other  times  not  ansesthetic. 

Disorders  of  Motility. — Hemiansesthesia  is  considered 
a  constant  symptom  of  hystero  epilepsy,  and  always  ac- 
companies anaesthesia  and  disappears  with  it  as  well. 
When  the  attack  is  approaching,  muscular  weakness  in- 
creases ;  the  patient  will  perhaps  be  unable  to  use  her  arm 
to  comb  her  hair,  and  is  unable  to  retain  a  grasp  of  objects 
with  her  hands.  By  the  djmamometer,  the  right  hand 
will  register  less  than  the  left,  the  proportion  being  six  to 
twenty- one. 

The  walk  is  uncertain,  the  patients  having  a  very  un- 
steady gait.  The  leg  of  the  anaesthetic  side  bends  under 
its  weight;  oftentimes  they  have  painful  cramps,  and 
marked  tremulousness.  The  condition  of  the  limb  per- 
mits exaggerated  reflex  movement  of  the  patella. 

Similar  to  the  tremor  of  true  epilepsy  is  that  which  oc- 
casionally troubles  these  patients.  It  consists  of  a  sudden 
tetanoid  state  of  a  group  of  muscles  of  short  duration,  end- 
ing as  suddenly  as  it  started,  thus  resulting  in  a  rapid 
movement  of  the  levers  from  which  the  tendons  of  the 
muscles  take  their  origin.  This  movement  may  be  com- 
pared to  that  produced  by  a  discharge  of  electricity. 


196  FUNCTIONAL   NEEVOUS   DISORDERS. 

This  tremor  will  at  one  time  be  limited  to  one  side  of 
the  body,  a  limb,  the  face,  the  abdomen,  etc.,  of  the  anaes- 
thetic side  being  selected,  and  then  again  the  whole  body 
may  be  affected.  When  the  patient  walks,  she  is  liable  to 
fall ;  when  sitting,  she  is  apt  to  be  suddenly  lifted  from  her 
seat,  only  to  fall  again  heavily.  The  attacks  are  most 
apt  to  occur  at  night,  at  the  approach  of  sleep,  but  they 
may  also  come  on  in  the  daytime.  At  night  she  may 
be  suddenly  awakened  with  the  feeling  that  she  is  fall- 
ing out  of  bed,  and  indeed  at  times  this  actually  takes 
place. 

During  the  prodromal  period,  the  tremblings  are  similar 
to  those  at  the  beginning  of  an  epileptiform  convulsion, 
and  during  the  few  seconds  preceding  the  crisis  they  occur 
more  and  more  rapidly,  until  they  become  absolutely  con- 
tinuous, and  epileptic  tetany  ushers  in  the  attack. 

Contracture  is  frequently  a  precursory  phenomenon  of 
the  crisis.  It  is  usually  partial  and  comes  on  suddenly. 
It  travels  from  one  part  of  the  body  to  another  until  all 
the  extremities  are  involved,  shortly  before  the  beginning 
of  the  attack.  The  contracted  limbs  vary  greatly  as  to 
position,  but  are  sometimes  affected  in  an  invariable  man- 
ner in  some  one  particular  patient.  Richer  considers  that 
the  contractures  should  be  classed  with  the  symptoms 
which  precede  the  major  attacks,  while  the  tremblings  be- 
long to  such  of  the  minor  attacks  as  in  some  particulars 
resemble  the  major  ones. 

Disorders  of  Sensation. — Anaesthesia,  or  more  often 
hemi-angesthesia,  is  a  symptom  of  hystero-epilepsy  in  the 
interval  between  the  attacks.  It  may  be  incomplete;  for 
instance,  the  prick  of  a  pin  will  be  felt  but  will  convey  no 
sensation  of  pain,  analgesia  being  present.  A  few  days 
previous  to  the  attack,  anaesthesia  comes  on,  if  not  already 


HTSTERO-EPILEPST.  197 

present,  and  takes  the  place  of  the  analgesia.  In  time  it 
becomes  fixed,  but  disappears  temporarily  in  the  intervals 
of  attacks.  Hypersesthesia  localized  in  certain  nerve 
areas  is  not  rare  in  hysterical  patients,  and  is  frequently 
found  among  the  prodromes  of  an  attack.  An  example  of 
this  may  be  seen  in  Rosenthal's  case,  already  mentioned, 
but  we  note  that  in  the  days  preceding  the  attack  it  is  re- 
placed by  anaesthesia. 

Special  sensation  is  also  affected,  on  the  same  side  as 
general  sensibility.  Both  are  equalty  affected  by  the  same 
agents.  This  does  not  mean  that  the  one  cannot  exist 
without  the  other.  Cutaneous  anaesthesia  may  exist  with- 
out involving  the  special  senses,  although  it  rarely  does. 
Anaesthesia,  likewise,  may  affect  some  special  sense,  with- 
out involving  the  skin. 

The  power  to  distinguish  colors  is  completely  lost,  and 
dyschromatopsy  becomes  achromatopsy.  Even  amblyopia 
may  be  well  marked. 

The  Hysterical  Aura. — The  real  attack  is  preceded  by 
the  prodromata  mentioned;  Charcot  thus  describes  the 
onset  of  the  convulsions. 

"  (1)  At  first  there  is  pronounced  and  intense  pain ;  the 
patients  complain  of  the  weight  of  the  bedclothes  and 
cannot  even  bear  to  be  touched ;  they  shrink  instinctively 
from  the  examining  finger.  The  abdomen  is  so  swollen  as 
to  present  a  perfect  clinical  picture  of  spurious  peritonitis, 
in  connection  Avith  the  sensitiveness  alluded  to.  Muscles 
and  skin  both  lend  themselves  to  the  delusion.  (2)  In 
another  instance  the  pain  will  only  be  aroused  by  pressure, 
and  then  it  will  be  noticed  that  (a)  the  skin  is  totally 
anaesthetic;  (b)  the  muscles,  if  relaxed,  may  be  pinched 
and  stretched  without  causing  pain ;  (c)  the  seat  of  pain 
being  found  to  be  neither  in  the  skin  nor  in  the  muscles, 


198  FUN"CTIONAL   NERVOUS    DISORDERS. 

we  must  pursue  the  examination  a  little  further,  and  dis- 
cover it  by  making  deep  pressure  into  the  abdomen." 

There  is  no  doubt  that  the  seat  of  pain  is  invariably  in 
one  place,  and  indeed  the  patients  themselves  will  always 
locate  it  there.  If  a  horizontal  line  be  drawn  from  one 
anterior  superior  spine  of  the  ilium  to  the  other,  and  upon, 
it  be  let  fall  the  perpendicular  lines  that  form  the  lateral 
boundary  of  the  epigastrium,  at  the  intersection  of  the 
horizontal  and  perpendicular  lines  will  be  found  the  spot 
which  is  the  seat  of  pain,  as  is  proved  by  its  sensitiveness 
to  the  touch. 

By  deep  exploration  of  this  region,  we  can  clearly  feel 
the  portion  of  the  inlet  which  describes  an  internally  con- 
cave curve.  At  about  the  centre  of  this  curve  we  usually 
find  an  ovoid  body  which  is  placed  transversely,  and  which 
slips  from  under  the  fingers  when  pressed  against  the  bony 
wall.  If  this  body  be  at  all  inflamed,  which  is  frequently 
the  case,  it  will  be  of  the  size  of  an  olive,  or  even  of  a 
small  egg.  With  a  little  practice  it  will  be  possible  to 
feel  it,  even  when  it  is  not  enlarged.  It  is  at  this  point  in 
the  exploration  that  the  pain  is  caused,  which  is  severe  in 
its  nature,  and  accompanied  by  all  or  some  of  the  phe- 
nomena of  an  hysterical  aura,  such  as  occurs  previously' 
to  an  attack. 

The  birthplace  of  the  aura  has  thus  been  found  by  the 
exploration,  which  has  also  caused  pain  in  the  region  of 
the  epigastrium,  complicated  at  times  by  nausea  and  vom- 
iting. If  pressure  be  continued,  palpitation  of  the  heart 
will  be  caused,  with  corresponding  rapidity  of  the  pulse, 
and  presently  the  globus  hystericus  will  make  its  appear- 
ance in  the  throat. 

Disturbances  in  the  head  are  apt  to  come  on  about  this 
time.     For  instance,  if  the  left  ovary  be  compressed,  a 


1,  1' .  Supra-Mammary  Zones 

2.  Mammary  Zones 

3,  3'.  Sub- Ancillary  Zones 

i,  i',  3.  Sub- Mammary  Zones 

6,  6'.  Costal  Zones 

7,  7'.  niac  Zones 
8,8'.  Ovarian  Zones 


PRINCIPAL  HYSTEROGENIC  ZONES 

ANTERIOR    ASPECT    OF    THE    BODY 


To  face  li-  109. 


HTSTEKO-EPILEPSY.  199 

sound  compared  by  the  patient  to  the  noise  of  a  steam 
whistle  will  be  heard  in  the  left  ear;  hammerings  are  felt 
on  the  left  temporal  region,  and  an  indistinctness  of  vision 
is  noticed  in  the  left  eye.  The  same  thing  would  occur  in 
the  right  eye  were  pressure  to  be  made  on  the  right  ovary. 

Investigation  cannot  well  be  carried  beyond  this  point, 
for  consciousness  begins  to  be  affected,  and  the  patient  can 
no  longer  give  an  account  of  her  sensations.  Further 
pressure  and  exploration  would  cause  the  immediate  ap- 
pearance of  the  crisis. 

At  the  approach  of  an  attack,  ovarian  pain  is  increased 
and  all  the  painful  phenomena  of  the  hysterical  aura  de- 
velop spontaneously.  At  first  they  are  infrequent  and 
slight  in  degree,  but  gradually  increase  in  frequency  at 
the  approach  of  the  attack. 

Hystero- Genetic  Zones. — We  have  seen  that  an  attack 
may  be  brought  on  by  pressure  upon  a  painful  ovary. 
That  is  evidently  the  starting-point  of  the  hysterical  aura, 
and  a  gentle  touch  suffices  to  call  forth  all  the  painful  phe- 
nomena which  make  up  that  aura.  If  the  irritation  be 
somewhat  prolonged,  a  major  attack  will  be  brought  on. 
Later  we  shall  see  that  the  same  method  used  to  cause  an 
attack  will  also  stop  it. 

The  ovarian  region  is,  however,  not  the  only  one  whose 
irritation  will  bring  on  or  arrest  the  convulsions.  The 
hystero-genetic  zones  have  a  constant  relation  to  hemi- 
ansesthesia.  Although  we  know  that  the  ovaritis  exists 
on  the  ansesthetic  side,  yet  several  cases  are  known  where 
the  ovaritis  was  on  the  side  opposite  to  the  ansesthesia. 
Sometimes  the  zone  is  on  the  median  line.  Gaube  has 
observed  hystero-genetic  zones  upon  the  limbs,  a  condition 
not  seen  by  Charcot  in  any  of  his  patients. 

These  zones  are  usually  situated  at  or  very  near  to  the 


200  FUNCTIONAL    NERVOUS    DISOEDERS. 

articulations.  We  find  them  in  the  hand,  the  elbow,  the 
groin,  in  the  popliteal  space,  and  at  the  ankle.  It  is  no- 
ticeable that  they  are  on  the  side  of  flexion.  Gaube  found 
that  when  the  zone  existed  in  a  limb,  compression  of  the 
nerve  trunk  of  that  limb  brought  on  an  attack  similar  to 
that  caused  by  pressure  upon  the  zone  itself.  He  found 
that  the  mammary  gland  is  a  hystero-genetic  zone  for  the 
viscera.  Pressure,  not  pinching,  must  be  used  in  this 
situation,  to  bring  on  a  convulsion. 

He  has  found  that  these  zones  are  more  often  seen  on 
the  anterior  than  on  the  posterior  portions  of  the  body 
and  limbs,  and  that  when  they  are  anterior  the}"  are  apt 
to  incline  to  the  lateral  portions  and  to  be  often  double 
and  symmetrical.  When  on  the  posterior  parts,  they  are 
usually  single  and  in  the  median  line,  and  oftener  on  the 
left  side  than  on  the  right.  According  to  both  Richer 
and  Gaube,  the  unilateral  zones  are  more  apt  to  be  on  the 
left  side.  These  zones  are  not  always  in  the  same  con- 
dition of  excitability,  but  are  more  easily  excited  when  an 
attack  is  near.  Their  sensitiveness  may  be  diminished  by 
the  application  of  a  mustard  paste,  the  production  of  local 
ansemia  (Esmarch's  bandage),  hypodermic  injections  of 
water,  and  local  electricity  with  the  continuous  or  the 
interrupted  current.  Metals  and  wood  have  the  same  re- 
sult, and  during  etherization  the  same  thing  occurs.  The 
ascending  or  descending  medullary  currents,  the  cerebral 
currents,  cause  the  disappearance  of  the  zones,  and  loss  of 
excitabilitj^  of  the  nerve  trunks  which  inhibit  them. 

It  is  an  undeniable  but  unexplained  fact  that  while  one 
irritation  of  a  zone  will  bring  on  convulsions,  a  second 
irritation  will  stop  them ;  but  while  a  mere  touch  will  serve 
to  bring  on  the  attack,  deeper  pressure  is  needed  to  arrest 
it.     When  a  patient  has  more  than  one  hystero-genetic 


Dorsal  Superior  Zone 
Horsal  Inferior  Zone 
Lateral  Posterior  Zone 


PRINCIPAL   HYSTEROGENIC  ZONES 


POSTERIOR    ASPECT 


To  face  p.  200. 


HTSTERO-EPILEPST.  201 

zone,  the  attack  caused  by  the  irritation  of  one  may  be 
brought  to  an  end  by  pressure  upon  another. 

We  are  indebted  to  Paul  Richer  for  most  of  the  preced- 
ing facts  relating  to  the  prodromal  symptoms  of  hystero- 
epilepsy.  No  one  else  has  given  the  subject  such  careful 
study  as  he.  Man}"  of  the  phenomena  are  undoubtedly 
rare,  but  they  are  certainly  interesting,  and  it  is  to  him 
that  all  credit  is  due  for  clearing  up  this  obscure  subject. 

Dr.  Arthur  Gamgee,  in  the  British  Medical  Journal 
for  October  12th,  1878,  gives  an  excellent  description  of  an 
hystero-epileptic  attack  which  he  witnessed  in  one  of  Dr. 
Charcot's  wards  at  the  Salpetriere.  There  were  also 
present,  among  others,  Drs.  Virchow,  Ernest  Hart,  Os- 
car Liebreich,  and  Stewart  Turner.  He  speaks  of  the 
inhibition  of  the  attack  by  pressure  in  the  ovarian  region. 
When  I  tried  this  manoeuvre  it  seemed  to  make  the  pa- 
tients worse  than  before ;  many  were  unable  to  bear  severe 
pressure.     The  following  is  from  Dr.  Gamgee's  article. 

"  The  patient,  a  j^oung  woman  of  considerable  vigor  and 
intelligence,  is  apparently  about  22  years  of  age,  and  is 
very  frequently  subject  to  the  most  characteristic  hystero- 
epileptic  attacks.  These  attacks  had  been  exceedingly 
frequent  on  the  day  preceding  our  visit,  but  had  been 
inhibited  by  the  systematic  application  of  pressure  to  the 
right  ovarian  region,  as  will  be  more  particularly  men- 
tioned in  the  sequel.     They  still  continued  to  recur. 

"  Professor  Charcot  pointed  out  that  the  hystero-epileptic 
seizure,  besides  occurring  spontaneously,  can  usually  be 
induced  with  ease  by  some  modes  of  peripheral  irritation. 
In  the  present  case  for  instance,  by  suddenly  'gripping' 
the  skin  of  the  breast  on  both  sides,  about  on  a  level  with 
the  fifth  rib  and  midway  between  the  anterior  and  pos- 
terior boundaries  of  the  axilla,  the  patient  instantly  fell 
into  the  hystero-epileptic  convulsion.     The  constancy  with 


202 


FU]SrCTION"AL    iiTEKVOIIS    DISOKDERS. 


which  the  effect  followed  the  cause  was  demonstrated  over 
and  over  again  to  be  absolute. 

"  Although  the  various  phenomena  of  the  hystero-epilep- 
tic  seizure  are  known  to  many  readers  through  the  writ- 
ings of  M.  Charcot,  it  may  not  be  uninteresting  to  describe 
them  with  all  minuteness  as  they  were  presented  before  us 
by  this  patient.  The  attack  may  be  conveniently  divided 
into  three  or  four  stages. 

"  Tlie  first  stage  followed  the  application  of  the  periph- 
eral irritation  without  the  intervention  of  any  perceptible 
latent  period ;   its  features  were  the  following :     The  head 


Fig.  22.— Second  Period.    The  Violence  of  the  Great  Movements. 

was  thrown  violently  backward,  the  limbs  and  body  be- 
came rigid,  the  respirations  infrequent  and  stertorous;  in 
a  few  seconds  the  tonic  spasms  were  succeeded  by  clonic 
spasms  affecting  the  muscular  system.  A  slight  remis- 
sion lasting  for  a  very  few  seconds  occurred,  which  was 
spoken  of  as  a  kind  of  entr^acte,  and  then  commenced 
the  second  stage.  The  first  may  be  termed  the  epilepti- 
form stage. 

"  The  second  stage  was  characterized  by  extraordinary 
movements  affecting  the  whole  trunk.  The  back  being 
somewhat  opisthotonically  arched,  the  bod}"  was  thrown 
with  great  violence  and  astounding  rapidity  alternately  on 


HYSTERO-EPILEPST. 


203 


to  the  occiput  and  heels.  This  stage,  which,  like  the  first, 
is  of  very  brief  duration,  is  denominated  the  phase  des 
grands  mouvements  ;  during  its  continuance  occur  the  first 
hallucinations,  to  be  afterward  referred  to.  The  violent 
movements  cease  almost  instantaneously  and  then  follows : 
"  The  third  stage  or  stage  of  emotional  attitudes  (phase 


Fig.  23.— Second  Period.     Contortions.    Demoniacal  Attack. 

des  attitudes  passionelles) .  During  this  stage  the  pa- 
tient assumes  successively  the  expression  of  face,  the  atti- 
tudes, and  the  gestures  which  portray  varied  emotions — in- 
tense and  vivid.  The  varied  emotional  states  will  be  dis- 
tinguished by  letters  in  the  order  in  which  they  occurred. 

"a.  No  sooner  had  the  great  movements  ceased,  than 
raising  herself  into  a  sitting  posture,  with  clenched  fists 


204  FUNCTIOlsrAL    NERVOUS    DISORDEES. 

and  menacing  expression,  the  patient  presented  the  most 
startling  picture  of  one  threatening ;  but  almost  instantly 
the  picture  changed  to 

"  h.  The  whole  expression  and  attitude  portrayed  cower- 
ing, abject  fear.  Of  no  longer  duration  than  a,  h  was 
followed  by  stage 

"  c.  The  patient  now  assumed  an  expression  of  absolute 
beatitude.  It  is  impossible  to  describe  the  look  of  saintly 
happiness,  as  of  one  who  realized  the  blessedness  of  heaven, 
which  the  patient  presented.  It  was  the  expression  which 
some  of  the  old  masters  have  impressed  upon  the  saints 
and  martj^rs. 

"  But  now  occurred  a  change  no  less  striking  than  the 
preceding. 

"  d.  The  expression  of  saintly  happiness  was  succeeded  by 
one  of  intense  joy ;  the  patient  sees  one  whom  she  loves ;  she 
beckonstohim  to  come,  to  come  quickly;  he  has  come.  .  .  . 
Then  succeed  gestures  which  stamp  this  as  the  phase  of 
lubricity^  or  the  stage  of  the  emotional  attitudes. 

"e.  Again  fear  takes  possession  of  the  patient;  at  first 
it  is  rats  which  she  sees  and  which  she  appears  to  fear 
the  attack  of,  which  evoke  passionate  exclamations  of 
dread  and  disgust ;  then  it  is  obviously  the  fear  of  some 
human  being  which  oppresses  her  and  causes  her  to  beg 
for  mercy. 

"/.  There  is  no  longer  fear.  The  patient  hears  the 
strains  of  music ;  she  is  pleased ;  she  herself  begins  to  hum 
the  tune,  but  only  for  an  instant,  for 

"  g.  Her  singing  is  followed  by  weeping,  which  is  broken 
by  reproaches  addressed  to  her  parents  as  the  cause  of  her 
misery.  This  last  phase  {g)  in  the  stage  of  passionate  at- 
titudes may  be  made  to  constitute  a  fourth  stage  or  a  stage 
of  recovery,  in  which  hallucinations  persist  for  a  time." 

The  following  table  will  illustrate  the  dependency  of 
this  grave  neurosis  upon  depressed  conditions  of  the  ner- 
vous system,  resulting  from  overwork  and  worry,  com- 
bined with  local  uterine  or  ovarian  or  digestive  disorder. 


HYSTEEO-EPILEPSY. 


205 


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HYSTERO-EPILEPST.  207 

The  following  extremely  severe  case  of  hystero-epilepsy 
is  well  worth  recording,  on  account  of  its  many  typical 
features.  The  particular  circumstance  in  this  case  to 
which  I  would  call  attention  is  the  fact  that  the  severity 
of  the  attack  was  not  at  all  diminished,  but,  on  the  con- 
trary, very  markedly  increased  by  pressure  on  the  right 
ovarian  region.  This  is  contrary  to  Charcot's  experience 
in  many  of  his  cases,  and  was  probably  the  result  of  the 
marked  inflammatory  condition  here  present. 

Case  I. — Hy stero- Epilepsy  ;  Right  Ovarian  Hyper- 
cesthesia,  Much  Delirium,  Severe  Pelvic  Inflamma- 
tion, Dysmenorrhcea  with  Cervical  Stenosis,  Resulting 
from  Criminal  Abortion. — Mrs.  R.,  aged  26,  blonde, 
divorc3d.  She  was  first  seen  in  January,  1885.  She  suf- 
fers much  mental  distress  on  account  of  separation  from 
her  husband.  She  has  been  ill  for  two  years  with  dys- 
menorrhcea dating  from  a  criminal  abortion.  She  was 
under  treatment  in  the  country,  and  her  physician  told 
her  that  she  had  a  small  tumor  of  the  right  ovary,  and 
also  a  pelvic  abscess.  On  examination,  I  find  marked 
stenosis  of  the  cervical  canal  a  half-inch  from  the  external 
OS,  with  great  tenderness  on  the  right  side  of  the  uterus. 
When  I  first  saw  this  patient  she  was  in  the  second 
period  of  the  attack,  that  of  contortions  and  great  move- 
ments, with  marked  opisthotonos.  While  pressing  over 
the  region  of  the  right  ovary  to  inhibit  the  attack,  she 
screamed  for  me  to  press  harder.  The  nurse  and  I  pressed 
with  all  our  strength,  but  it  did  not  seem  to  give  her 
much  if  any  relief  from  the  terrible  pain.  During  the 
period  of  delirium,  she  has  the  hallucination  that  she  sees 
her  husband,  and  begs  and  entreats  him  to  come  to  her 
(repeating  constantly,  "Oh  come,  George,  do  come,"  and 
finally  crying  out  in  the  deepest  anguish,  "Oh,  George, 
why  do  you  not  come?"),  the  expression  on  her  face  in- 
dicating the  emotion  of  piteous  supplication.  She  had 
hemianaesthesia,  but  not  quite  complete,  of  the  right  side, 


208 


FUiirCTIOS'AL   JS'ERYOUS    DISOEDEilS. 


HYSTEEO-EPILEPSY.  209 

with  a  feeling  of  numbness  and  severe  pain  at  times  from 
the  knee  to  above  the  hip ;  right  hand  and  foot  cold,  with 
partial  hemiplegia ;  she  complained  of  great  and  constant 
pain  in  the  top  of  the  head.  She  expressed  it,  "as  if  the 
crown  was  raised  up  and  came  down  with  a  crash."  After 
the  attack,  there  are  constant  throbbing  and  cutting  pains 
in  the  pelvic  abdomen,  and  over  the  region  of  the  right 
ovary  there  is  tenderness.  She  feels  at  times  feverish,  and 
then  cold  with  clammy  perspirations.  There  is  spinal 
tenderness  from  the  level  of  the  angles  of  the  scapulae  to 
the  sacrum,  and  she  has  throbbings  and  twitchings  through 
the  whole  right  side,  even  to  the  fingers  and  toes.  The 
right  arm  aches,  and  there  is  numbness  in  the  right  side 
all  the  time.  No  trouble  on  the  left  side,  except  pain  over 
the  region  of  the  heart  after  a  deep  inspiration.  Appetite 
poor,  tongue  heavily  coated,  and  breath  foetid.  I  gave  her 
bromide  of  potassium  and  the  elixir  of  the  valerianate  of 
ammonia  in  large  doses,  with  injections  of  asafoetida  dur- 
ing the  attack,  with  no  benefit.  I  afterward  made  a  slight 
dilatation  of  the  cervical  canal  with  my  steel  dilator  and 
applications  of  the  faradic  current  to  the  right  side 
without  any  improvement. 

The  very  peculiar  hallucinations  experienced  by  the 
patient  in  the  following  case  are  of  interest.  The  case  is 
one  of  characteristic  hystero-epilepsy,  but  there  is  partial 
consciousness  during  the  period  of  the  grand  movements. 

Case  II. — Hy stero- Epilepsy  ;  Eight  Ovarian  Hyper- 
cesthesia,  Much  Delirium,  Dysmenorrhoea,  Constant 
Leucorrhoea,  Lacerated  Perineum,  Tivo  Abortions. — 
Mrs.  B.  age  44,  has  had  six  children  and  two  miscar- 
riages. She  has  a  cousin  who  is  a  cataleptic.  Ten  years 
ago  she  had  a  sunstroke,  and  "  since  then  has  been  feeling 
miserable."  She  works  hard,  and  is  burdened  with  a 
shiftless  husband,  who  causes  her  a  great  deal  of  anxiety. 
For  a  week  before  the  attack,  which  alwaj's  comes  on  just 
as  the  menstrual  flow  begins,  there  are  prodromes — she  has 
14 


210  FUNCTIOKAL    NERVOUS   DISOEDEES. 

dull  headaches,  is  irritable  and  nervous,  has  great  thirst, 
and  her  feet  are  icy  cold.  Two  days  before  the  menstrual 
period  her  head  feels  queer.  There  is  also  palpitation  of 
the  heart.  She  has  hallucinations,  imagines  that  an}^  ob- 
ject seen  is  of  enormous  size — as,  for  instance,  a  chair — and 
wonders  if  she  could  ever  walk  around  it.  During  the 
attack  she  has  a  dull,  heavj^  pain  in  the  right  ovarian  region 
and  down  the  thighs,  and  a  terrible  pain  at  the  base  of  the 
brain.  During  the  stage  of  contractions,  there  is  slight 
opisthotonos,  and  after  the  clonic  grand  movements  her 
strength  leaves  her,  she  is  completely  exhausted  and 
drops  into  a  deep  sleep.  There  is  partial  consciousness 
during  the  stage  of  grand  movements.  She  can  tell  that 
there  "  are  people  around  her,  and  that  something  is  mov- 
ing." In  this  stage,  she  casts  herself  all  over  the  bed,  and 
struggles  frightfully.  She  has  been  under  treatment  by 
several  physicians,  and  says  the  only  thing  that  gives  her 
the  slightest  relief  is  ordinary  bottled  sodawater.  She  is 
weak,  and  has  leucorrhoea.  On  examination,  I  find  the 
uterus  tender,  but  of  normal  size  and  position.  There  is 
tenderness  in  both  ovarian  regions,  greatest  on  the  right 
side,  and  a  cellulitic  deposit  behind  the  uterus.  She  has 
endometritis  and  a  lacerated  perineum.  In  some  of  her 
attacks  there  is  demoniacal  fur}';  in  one  she  drove  her 
son  and  daughter  from  the  house. 

In  the  case  of  the  following  patient,  as  in  all  other  suf- 
ferers from  this  disorder,  the  condition  is  a  cerebro-spinal 
neurosis — here  especially  apparent — and  the  hysterical  ele- 
ment is  particularly  well  marked.  As  in  the  other  cases 
recorded,  there  are  many  points  of  extreme  interest — the 
spinal  irritation,  the  pains  in  the  head  during  delivery, 
the  bronchial  hystero-neurosis,  and  hysterical  attacks  fol- 
lowing the  slightest  excitement. 

Case  III. — Hij stero- Epilepsy  ;  Ovarian  HypercBstlie- 
sia,  a  Bronchial  Hy stero- Neurosis,  Dysmenorrlioea^ 
Two  or  Three  Abortions. — Mrs.  B.,  divorced  woman,  age 


HTSTERO-EPILEPST.  211 

38,  has  had  five  children  and  two  abortions.  She  has  had 
attacks  since  her  second  child  was  born  in  1878.  During 
the  labor,  which  was  brought  on  at  eight  months  by  fright, 
all  the  pains  "  were  in  her  head,"  and  she  was  unconscious 
until  after  deliver}-.  The  attack  comes  on  with  globus 
hj^stericus,  followed  by  a  sinking  sensation  and  uncon- 
sciousness. I  first  saw  this  patient  in  February,  1885. 
She  was  taken  with  an  attack  at  the  dining-table  from  the 
excitement  of  an  unpleasant  interview  with  her  sister.  In 
the  first  or  epileptic  stage,  she  stiffened  in  her  chair  with 
her  extremities  extended,  thumbs  flexed  tightly  on  the 
palms  of  her  hands,  jaws  firmly  set,  and  eyes  closed; 
clonic  spasms  succeeded,  and  were  followed  by  the  stage 
of  resolution.  She  has  spinal  irritation  from  occiput  to 
coccyx,  and  the  least  excitement  brings  on  pain  in  the  back 
of  the  head.  She  used  to  have  "  cramps"  during  menstrua- 
tion, which  were  always  profuse,  lasting  usually  six  or 
seven  days.  Just  before  menstruating,  she  always  has 
pains  in  the  head  and  "a  real  bad  cough" — a  bronchial  hys- 
tero-neurosis.     She  is  hysterical  from  the  least  excitement. 

In  the  next  case,  as  with  the  generality  of  divorced 
women,  as  well  as  in  those  who  have  departed  from  the 
paths  of  virtue,  the  resulting  worry  and  mental  depression 
were  exciting  causes  of  the  attack.  The  complication  of 
soinnambulism  is  here  specially  noteworth3\ 

Case  IV. — Hystero-Epilepsy  ;  Ovarian  Hypercesthe- 
sia  on  Both  Sides,  Somnambulism,  Dysmenorrlicea,  Five 
Abortions. — Mrs.  IST.,  age  42,  a  tall  robust  brunette,  di- 
vorced. She  has  had  five  children  and  five  abortions; 
but  has  not  been  pregnant  since  the  birth  of  her  last  child, 
who  is  now  15  years  old.  All  deliveries  have  been  instru- 
mental from  pelvic  deformity.  She  says  that  with  each 
of  her  last  three  labors  she  had  an  attack,  and  the  child 
was  born  while  she  was  unconscious.  The  last  child  was 
born  while  she  was  in  the  opisthotonic  position.  Her  first 
attack  was  at  the  birth  of  her  third  child,  it  being  a  second 


212  PUNCTIOXAL   NERVOUS    DISORDERS. 

confinement  in  twelve  months ;  at  this  time  she  was  slight 
and  very  weak.  The  attack  came  on  from  extreme  mental 
excitement  and  worry,  caused  by  trouble  with  her  husband. 
Has  prodromes,  consisting  of  faint  feelings,  a  queer  sensa- 
tion in  the  head,  flushing  of  the  face,  and  gradual  uncon- 
sciousness. The  attack  comes  on  a  day  before  menstrua- 
tion, and  on  the  second  day  of  terrible  pain  she  experiences 
relief  on  the  appearance  of  the  flow  which  is  always  pro- 
fuse. She  is  always  very  much  depressed  and  downhearted 
before  and  after  the  attack.  She  has  broken  some  of  her 
teeth  in  the  tetanic  contractions  of  the  epileptoid  period. 
She  is  much  prostrated  after  it  and  remains  in  bed  for  a 
week.  There  are  no  hystero-genetic  zones  or  painful  spots 
except  over  both  ovarian  regions.  After  the  attack  she 
has  hallucinations,  also  achromatopsia  and  amblyopia. 
During  some  of  the  attacks  she  has  somnambulism,  walks 
around  the  street  in  her  nightclothes,  and  has  to  be  led 
home. 

The  predominance  of  the  stage  of  delirium  and  maniacal 
excitement  from  the  sudden  arrest  of  the  menses  and  the 
severe  pain  resulting  are  prominent  points  in  the  follow- 
ing case.  Severe  gastralgia,  due  to  uterine  disease,  is  a 
common  exciting  cause  of  hystero-epilepsy.  This  case  is 
very  similar  to  many  reported  from  La  Salpetriere. 

Case  V. — Hystero-Epilepsy  j  Ovarian  Hypercesthe- 
sia,  Period  of  Delirium  Predominating,  Dysmenor- 
rhoea,  Sudden  Suppression  of  Menses,  PJndocervicitis, 
Tivo  Abortions. — Mrs.  B.,  age  24,  is  of  lively  disposition, 
and  has  been  six  years  married.  She  first  menstruated  at  14 ; 
has  one  child  aged  5  years ;  has  had  two  criminal  abortions, 
the  last  three  years  ago,  and  since  that  time  she  has  had, 
at  every  third  or  fourth  menstrual  period,  severe  "  cramps" 
in  the  epigastrium,  and  they  grow  worse  each  time.  On 
July  4th,  1887,  the  second  day  of  her  menstrual  period, 
she  caught  cold  by  stepping  with  her  bare  feet  on  an  oil- 
cloth after  getting  out  of  bed.     This  arrested  the  menstrual 


HYSTERO-EPILEPSY. 


213 


iFiG.  25.— Fourth  or  Period  of  Delirium. 


214  FUNCTIOSrAL   NERVOUS    DISOKDEES. 

flow,  and  at  eleven  o'clock  p.m.  the  attack  came  on  with 
grinding"  of  the  teeth  from  the  severe  pain  in  the  epigas- 
trium, and  with  contractions  of  the  muscles  of  the  neck. 
There  was  wild  delirium,  it  requiring  three  or  four  per- 
sons to  hold  her.  In  her  demoniacal  rage,  she  tore  her 
clothes  to  rags,  imagined  that  she  was  on  the  elevated  or 
cable  roads,  was  snow-balling,  or,  the  next  moment,  swim- 
ming in  the  surf.  She  fondled  a  pillow  for  her  child,  and 
rushed  about  the  room  striking  herself  against  objects  with 
great  force.  I  gave  her  one-third  of  a  grain  of  morphine 
by  hypodermic  injection,  and  she  gradually  became  calm, 
recognized  her  surroundings,  and  fell  asleep.  These  at- 
tacks last  nearly  three  hours.  She  was  weak  and  ex- 
hausted for  some  days  following.  She  was  too  sore  and 
tender  over  the  ovarian  regions,  particularly  the  right,  to 
admit  of  any  pressure.  There  was  extreme  pain  in  the 
epigastrium  (which  was  swollen)  and  under  the  angles  of 
both  scapulae;  also  cervical  endometritis. 

Heredity  is  an  important  element,  sometimes  two  or 
more  of  the  same  family  having  the  disease. 

Case  VI. — Hystero- Epilepsy  ;  OvarHan  Hypercesthe- 
sia,  Nullipara,  Overwork  and  Anxiety,  Severe 
Menorrhagia. — Mrs.  D.,  age  30,  is  a  cousin  of  Miss  B.  of 
Case  VIII. ;  by  occupation  she  is  a  dressmaker,  and  is  a 
tall,  well-formed,  handsome  brunette,  with  a  nervous 
manner;  She  has  another  cousin  who  is  an  epileptic. 
Five  years  ago  had  her  first  attack,  brought  on  by  mental 
excitement,  while  sitting  in  a  warm  room,  followed  by  two 
more  in  rapid  succession.  August  16th,  1888,  while  in  a 
drug  store  waiting  for  some  medicine,  she  had  an  attack 
from  the  excitement  of  seeing  Miss  B.  in  her  paroxysms. 
It  came  while  she  was  sitting  in  a  chair,  and  as  conscious- 
ness returned  she  had  a  recollection  of  the  clonic  con- 
vulsive movements  of  her  hands  and  right  foot.  The 
attack  is  preceded  by  heart  palpitation  and  hysterical 
suffocation,  and  is  immediately  followed  by  unconscious- 
ness.    The  different  stages  in  this  case  are  similar  in  over}' 


HYSTERO-EPILEPSY.  215 

respect  to  those  of  her  cousin's  case.  Her  menses  occur 
every  two  or  three  weeks,  are  painless  and  profuse,  lasting 
seven  to  eight  days.  She  complains  of  pains  in  the  small 
of  the  back ;  her  bowels  are  regular,  and  she  passes  large 
quantities  of  dark,  heavy  urine  free  from  albumin.  When- 
ever she  is  excited  she  is  afraid  of  an  attack.  Her  father 
had  several  attacks  of  very  severe  epistaxis,  and  finally 
died  of  cerebral  hemorrhage.  A  brother  has  lately  died  of 
phthisis,  and  another  brother,  as  well  as  herself,  frequently 
has  attacks  of  bronchitis. 

That  somnambulism  and  catalepsy  are  often  part  of  the 
attack  is  well  exemplified  in  the  following  case.  We 
may  also  note  the  great  number  of  attacks  in  a  single  day 
(eighteen)  and  the  hypersensitiveness  of  the  nervous  sj'S- 
tem,  the  heart  palpitating  upon  the  slightest  exertion. 

Case  VII. — Hy stero- Epilepsy ;  Left  Ovarian  Hyper- 
cesfhesia,  Trance  or  Cafaleptoid  State,  Somnambulism, 
Dysmenorrhcea,  Slight  Floiv,  Constant  Leucorrhoea. — 
Mrs.  B,,  age  23,  had  her  first  attack  at  17,  from  fright. 
She  has  always  worked  hard.  At  20,  she  had  an  attack 
from  inhaling  gas  for  extraction  of  a  tooth.  She  says 
that  on  one  very  warm  day  she  had  eighteen  attacks,  and 
that  it  required  several  people  to  hold  her.  She  is  preg- 
nant for  the  first  time,  and  fright  from  the  quickening 
gave  her  an  attack.  Her  head  has  a  tight,  compressed 
feeling ;  there  is  no  outcry  nor  frothing  at  the  mouth ;  she 
falls  and  stiffens,  or,  if  in  a  chair,  slides  to  the  floor  feet 
first.  She  is  opisthotonic  during  attack,  consciousness 
being  lost  for  fifteen  or  twenty  minutes,  is  then  dizzy  and 
sometimes  vomits.  She  often  has  prodromes  for  an  hour 
before  the  attack— is  hysterical,  feels  oppression  of  breath- 
ing and  headache  at  the  vertex ;  at  other  times  no  notice 
is  given.  The  heart  palpitates  upon  the  slightest  exertion. 
When  younger,  she  had  severe  leucorrhoea  before  men- 
struating and  pain  in  the  small  of  the  back.  She  is  very 
weak;   the   menstrual   flow  is  scanty,    but   she   has   had 


216  FUl^CTIONAL    ISTERVOUS    DISORDERS. 

vicarious  flow  from  the  nose.  Seven  years  ago  she  had 
"brain  fever"  caused  by  overstudy  (?)  and  her  mother's 
death,  was  four  months  in  bed,  and  frequently  delirious 
and  maniacal.  In  the  attack,  during  the  period  of  de- 
lirium, she  imagines  that  others  are  trying  to  do  her  bodily 
harm.  She  is  a  somnambulist,  but  is  usually  detected  im- 
mediately upon  rising  or  after  a  short  walk.  She  is  also 
hystero-cataleptic,  the  condition  always  coming  on  at  night 
in  bed ;  she  has  a  sensation  of  smothering,  and  can  neither 
answer  nor  move  when  spoken  to.  She  has  had  these 
cataleptic  attacks  nearl}^  every  night  for  a  week.  The 
pain  is  in  the  left  ovarian  region.  She  has  malarial  symp- 
toms, chills,  fever,  perspiration,  and  drowsiness. 

The  ophthalmic  hystero-neurosis,  amblyopia  of  the  left 
eye,  being  a  reflex  phenomenon  from  left  ovarian  irrita- 
tion, is  interesting  (see  plate).  Indeed,  almost  everything 
connected  with  these  cases  is  remarkable  and  of  interest. 
In  a  much  milder  form  it  is  not  uncommon.  Abdominal 
pressure  in  such  cases  increases  the  severity  of  the  attacks. 
The  majority  of  these  patients  are  very  melancholic. 

Case  VIII. — Hystero-Epilepsy  ;  Hystero- Catalepsy 
and  Ecstasy,  Left  Ovarian  Hypercesthesia,  Cutaneous 
Anaesthesia,  Amblyopia  of  Left  Eye  an  Ophthalmic 
Hystero  -  Neurosis,  Dysmenorrhcea,  Irregular  and 
Scanty  Flow,  Continuous  and  Severe  Leucorrhoea. — 
Miss  B.,  age  21,  is  a  tall,  well-nourished  blonde.  Her 
parents  are  dead — father  from  cancer,  mother  from 
nephritis,  and  she  lives  with  her  brothers,  who  abuse  her 
and  are  a  source  of  constant  anxiety.  For  a  year  has 
had  pain  and  swelling  over  the  left  ovary,  pain  being 
severe  in  character  and  of  short  duration.  At  times  her 
feet  swell  at  the  insteps.  She  urinates  but  seldom  and 
onl}^  in  small  amounts ;  the  urine  contains  no  albumin;  she 
has  severe  unilateral,  migrainous  headaches,  left  side  anS 
left  eye,  every  other  day.     Menstruation  is  irregular,  scanty, 


HYSTERO-EPILEPSY.  217 

and  painful.  Her  first  attack  was  two  weeks  before  I  saw 
her.  She  falls,  becomes  unconscious,  and  convulsion  fol- 
lows. The  attack  comes  on  with  sobbing,  hysterical  suffo- 
cation, and  palpitation  of  the  heart.  There  is  a  state  of 
tonic  contraction  of  the  muscles,  which  is  followed  by 
opisthotonos.  After  a  little  the  right  leg  is  thrown  vio- 
lently over  the  left  in  the  air,  and  the  stage  of  resolution 
gradually  supervenes.  She  then  lies  in  an  exhausted  con- 
dition, and  finally  goes  into  a  heavy  sleep.  I  saw  this 
patient  again  the  day  following  another  attack,  and  found 
her  ecstatic  in  the  position  of  "crucifiement"  with  eyes 
looking  upward,  in  a  condition  of  hystero-catalepsy.  She 
was  totally  unconscious  during  the  attack,  her  skin  was 
cold  and  colorless,  and  her  pulse  weak.  After  her  second 
attack  there  was  partial  loss  of  sensation  in  her  lower 
extremities.  Her  abdomen  was  very  sensitive  to  pressure, 
and  she  was  threatened  with  an  attack  when  pressure  was 
continued.  I  saw  her  two  years  after;  she  had  had  no 
return,  but  she  says  that  ever  since  the  attacks  she  is 
afraid  of  herself  in  the  horsecars.  Leucorrhoea  is  severe 
and  continuous. 

Severe  pains  at  menstruation  are  probably  among  the 
most  common  causes  of  hystero-epilepsy,  as  they  are  pres- 
ent in  a  great  number  of  cases,  and  seem  often  to  be  the 
sole  cause  of  the  attack. 

Case  IX. — Hystero-Epilepsy  ;  Ovarian  Hypercesthe- 
sia,  Much  Delirium,  Dysmenorrhoea,  Irregular  and 
Scanty  Floiv. — Miss  S.,  age  18,  is  single,  rather  plump, 
emotional.  Her  father  died  from  phthisis;  her  mother  suf- 
fers with  neuralgia  and  is  verj^  melancholic.  While  visit- 
ing in  the  house  of  Case  II.,  she  was  taken  with  an  attack 
while  sitting  in  a  chair.  Her  friends  first  noticed  a  pecu- 
liar expression  upon  her  face,  and  immediately  after  she 
was  seized  there  was  abdominal  pain  followed  by  the  dif- 
ferent phases  of  the  hystero-epileptic  attack.  During  the 
stage  of  delirium  she  screamed  piteously  for  her  dead 


218  FUlfCTIONAL    NEEVOUS    DISOEDERS. 

father  to  come  and  take  her  home.  She  slept  all  the  next 
day,  and  while  returning  home  that  evening  was  taken 
with  the  seizure  in  the  horsecar,  and  carried  unconscious 
to  the  sidewalk.  The  opisthotonic  position  in  her  case  is 
most  marked.  Creeping  sensations  precede  the  attacks, 
and  there  is  always  occipital  headache.  There  is  also  ex- 
treme constipation,  sometimes  lasting  a  week.  She  has 
had  these  attacks  now  for  several  months.  The  first  was 
caused  by  the  fright  of  being  chased  at  night  by  a  man. 
Menses  are  scanty,  with  terrible  d3^smenorrhoeal  pains, 
and  last  only  a  day  and  a  half. 

Case  X. — Hystero- Epilepsy  ;  Left  Ovm^ian  Hyper- 
cesthesia,  Much  Delirium,  Dysmenorrhcea,  Slight  Flow, 
Endometritis,  Constant  Leucorrhcea. — Mrs.  S.,  age  27, 
has  been  married  five  years;  she  is  strongly  built.  She  has 
had  attacks  of  hystero-epilepsy  for  the  past  seven  years, 
coming  on  at  first  from  a  fright.  The  first  sensation  is 
that  of  trembling.  Her  hands  become  cold  and  there  is 
dizziness  or  faintness,  followed  by  unconsciousness  until 
the  period  of  contortions,  when  consciousness  returns.  Dur- 
ing the  attack  she  assumes  the  opisthotonic  position,  and 
froths  at  the  mouth,  the  froth  being  frequently  tinged  with 
blood.  She  believes  the  severe  abdominal  pain  to  be  the 
cause  of  the  attack,  although  it  may  be  brought  on  by  other 
things.  She  is  excessively  nervous  and  depressed  after  it. 
Headaches  are  usually  in  the  vertex,  but  are  sometimes 
occipital;  she  is  always  nauseated  upon  rising  and  after 
eating;  she  has  a  voracious  appetite;  she  is  always  con- 
stipated. There  is  pain  in  the  left  ovarian  region.  A 
cold  drink  always  gives  severe  cutting  pains  in  the  hypo- 
gastrium.  Menstruation  lasts  from  one  day  and  a  half  to 
two  days,  and  pain  comes  on  about  a  day  later.  She  has 
much  anxiety  on  account  of  a  worthless  husband. 

Examination :  At  the  internal  so,  on  passage  of  the 
sound,  there  is  great  sensitiveness.  She  has  constant 
leucorrhcea.  Since  treatment  directed  to  the  uterus  and 
ovaries,  the  attacks  are  much  less  frequent  and  less  severe. 

Finally,  after  a  short  time  the  headaches  left,  her  menses 


HYSTERO- EPILEPSY.  219 

became  normal,  pain  ceased,  and  she  was  apparently  en- 
tirelj^  cured. 

Criminal  abortion,  with  its  resulting  local  disease  and 
its  injurious  effect  upon  the  mind,  is  a  common  factor  in 
the  causation  of  these  cases.  As  a  class,  hystero-epileptics 
are  inferior  and  unintelligent,  and  full  of  humbug,  pre- 
tense, and  vanit3^  They  are,  as  a  rule,  weak-minded 
creatures. 

Case  XI.  —Hystero-Epilepsy  ;  Ovarian  Hypercestke- 
sia,  Trance  or  Epileptoid  State,  Hysterical  Trismus^ 
Amblyopia  an  Ophthalmic  Hystero- Neurosis,  Dysmen- 
orrhoea,  Endometritis,  Perimetritis,  Two  Criminal 
Abortions. — Mrs.  L.,  age  32,  has  been  married  ten  years, 
and  has  one  child.  She  has  had  two  criminal  abortions  at  six 
weeks.  When  a  girl,  she  had  attacks  which,  from  descrip- 
tion, were  probably  hystero-epileptic,  and  had  dysmenor- 
rhoea  until  she  became  pregnant.  She  has  had  two  hys- 
tero-epileptic attacks  during  the  past  year.  She  also  has 
nervous  spells,  when  she  grows  cold,  and  there  is  a  roaring 
and  throbbing  in  the  head  and  a  blurring  of  the  vision. 
It  is  not  a  fainting  condition.  She  thinks  that  she  has 
warded  off  some  of  these  nervous  spells  by  her  will  power. 
Occasionally  in  the  afternoon,  while  taking  a  light  sleep 
on  the  bed  or  sofa,  this  state  comes  on.  She  remains 
conscious,  but  cannot  stir  hand  or  foot;  her  extremities 
feel  as  cold  as  ice.  During  this  state  she  is  "  frightened 
and  prays  for  God's  help  to  move."  She  has  a  sensation 
of  shaking  or  quivering  through  every  part  of  the  body. 
She  dreams  a  great  deal  at  night.  A  short  time  ago  she 
consulted  me  for  hysterical  trismus ;  it  passed  away  and 
"went  to  the  stomach,"  as  she  expressed  it,  when  I  was 
called  and  had  to  give  her  a  hypodermic  injection  to  re- 
lieve the  pain.  She  has  had  hysterical  lockjaw  twice  be- 
fore, and  her  doctor  said  "it  was  the  wisdom  tooth,  that 
didn't  have  room  to  come  through."  She  has  chronic 
endometritis  and  perimetritis. 


•220  FUIfCTIONAL   NERVOUS    DISORDERS. 

It  will  be  of  interest  to  contrast  the  following  case  with 
the  foregoing,  as  the  two  conditions  are  sometimes  con- 
sidered to  be  the  same.  The  hj'steric  element  is  here 
entirely  wanting. 

Case  XII. — Haut  Mai ;  Menses  Habitually  Delayed, 
.Amblyopia,  No  Hysterical  Symptoms,  Has  an  Ovarian 
Aura. — Mrs.  C,  age  22,  was  married  at  nineteen,  and 
lias  one  child.  She  first  menstruated  at  fifteen,  and  the 
period  usually  occurs  every  five  or  six  weeks.  The  first 
attack  occurred  a  year  after  marriage,  and  it  came  on,  as 
have  her  succeeding  attacks,  when  she  was  expecting  her 
menses.  At  the  time  for  regular  menstruation,  there 
<;omes  a  sensation  of  weight  in  the  hypogastrium,  and 
while  waiting  for  the  flow,  which  is  always  scanty,  to 
-appear,  the  blood  seems  to  rush  to  her  head  upon  the 
slightest  exertion,  with  a  feeling  as  if  her  head  would 
burst.  The  eyes  are  affected  with  a  blurring  of  vision, 
and  most  of  the  pain  is  frontal.  During  the  attack  she 
grows  pale,  there  is  strabismus,  and  the  muscles  of  the 
face  are  contracted.  In  the  last  attack  several  teeth  were 
broken.  Her  last  menstruation  was  delayed  twenty  days. 
She  has  no  hysterical  symptoms  whatever.  As  soon  as 
"the  menstrual  flow  apjjears  she  feels  all  right. 

Case  XIII. — Convulsions  tuith  Dysmenorrhoea,  Nei- 
tlier  Hysteric  nor  Epileptic. — Miss  B.  S.,  age  37,  for 
fourteen  years  had  little  trouble  at  the  menstrual  period ; 
menses  first  appeared  at  18,  and  then  stopped  for  a  year. 
She  thinks  the  flow  was  never  regular;  it  was  always 
slight  in  amount,  lasting  from  one  to  two  days.  When  23 
years  old,  while  lifting  a  heavy  tub,  she  "  felt  something 
break  inside,"  and  has  been  ill  ever  since.  She  has  pains 
•of  a  xevy  severe  cutting  nature  in  the  left  ovarian  region, 
very  severe  congestive  and  neuralgic  occipito-basal  and 
frontal  headaches,  with  much  swelling  of  the  face  and 
neck.  These  come  on  as  menstruation  stops,  rarely  before 
it  appears,  and  are  preceded  by  severe  shakings  or  convul- 
sions.     She  does  not  feel  cold,  neither  is  there  any  fever. 


HTSTERO-EPILEPSY.  221 

Slight  pressure  over  the  left  ovarian  region  gives  a  little 
relief,  but  severe  pressure  causes  great  pain  and  increases 
the  convulsive  trembling.  There  is  no  loss  of  conscious- 
ness, and  there  are  no  hysterical  manifestations.  She  has 
lately  developed  an  asthmatic  neurosis.  When  the  attack 
skips  one  menstrual  period,  it  comes  v^ith  redoubled  force 
the  next  time.  Local  treatment  with  boro-gylceride  tam- 
pons and  hot-water  irrigation  always  improves  her  con- 
dition. Bromide  of  potassium  and  morphine  injections 
help  the  headaches.     She  has  a  tender  and  inflamed  uterus. 

Catalepsy,  Trance,  Lethargy,  Somnambulism,  Cata- 
leptoid  State. — Trance,  lethargy,  somnambulism,  and 
hystero-catalepsy  are  probably  only  modifications  of  the 
same  state;  lethargy  and  trance  are  often  complicated 
with  cataleptic  phenomena,  and  the  cataleptoid  state  can 
easily  be  impressed  on  either.  Somnambulism  often  ap- 
pears in  the  great  hysterical  attack  as  one  of  its  promi- 
nent features.  Catalepsy  in  these  cases  is  sometimes 
limited  to  the  upper  extremities,  and  to  impress  a  catalep- 
toid state  on  the  subject  of  trance  or  lethargy  the  member 
should  be  held  for  a  few  seconds,  when  it  usually  becomes. 
rigid,  and  then  again  by  friction  the  catalepsy  may  b© 
made  to  disappear.  In  all  these  conditions  there  is  fre- 
quently great  mental  activity. 

Richer  divides  lethargy  into  the  following  varieties: 

1.  Attacks  of  simple  lethargy. 

2.  Attacks  of  lethargy  with  apparent  death.  ■ 

3.  Attacks  of  complicated  lethargy. 

(a)  By  contractions,  partial  or  general. 

(b)  By  cataleptoid  state. 

Attacks  of  trance  or  lethargy  with  apparent  death  have 
been  recorded  by  reputable  writers,  and  there  is  but  little 
doubt  that  some  persons  in  this  state  have  been  buried 


222 


FUNCTIONAL    NEEVOUS    DISORDERS. 


alive.  Catalepsy  or  trance  may  be  defined  as  a  state  in 
which  general  motion  and  sensation  are  suspended,  but 
some  one  or  more  of  the  special  senses  remain  active.  In 
this  state  there  is  probably  local  or  general  modification  of 
the  cerebral  circulation. 

The  following  contrast  is  made  by  Richer : 


Catalepsy. 

The  cataleptic  state  is  general, 
aflfecting  equally  all  the  volun- 
tary muscles. 

The  cataleptic  state  is  de- 
veloped instantly ;  the  member 
keeps  the  position  as  soon  as 
communicated. 

Suppleness  and  lightness  of 
the  members. 

No  rigidity  of  the  members. 

The  cataleptic  state  is  in  no 
nanner  influenced  by  superficial 
cutaneous  excitations. 

The  cataleptic  state  is  primi- 
tive. 


Cataleptoid  State  of  Somnam- 
bulism. 

The  cataleptoid  state  is  partial. 

The  cataleptoid  state  comes 
gradually  after  superficial  cutane- 
ous excitation  (passes,  currents 
of  air,  blowing,  etc.). 

The  members  are  always  in  a 
state  of  rigidity,  of  which  the 
degree  varies  from  waxen  flexi- 
bility up  to  contracture. 

The  cataleptoid  state  ceases  in 
the  same  manner  in  which  it 
has  been  provoked,  that  is  to  say, 
after  superficial  cutaneous  exci- 
tations. 

The    cataleptoid    state     is    sec- 


ondary. 

Catalepsy  is  not  properly  speaking  a  disease  per  se,  but 
is  merely  one  of  the  train  of  manifestations  of  affections 
of  the  nervous  system.  It  is  a  far  more  common  condition 
in  weak  and  hysterical  women  than  is  generally  supposed. 
There  is,  as  a  rule,  no  danger  connected  with  it.  Attacks 
vary  in  duration  from  a  few  minutes  to  many  days.  It  is 
a  disorder  in  which  there  is  loss  of  consciousness,  sensation, 
and  voluntary  motion,  attended  with  a  remarkable  rigidity 
of  the  body.  In  some  cases  there  is  a  deprivation  of  mus- 
cular power  with  perfect  consciousness  existing,  while  in 
other  cases  the  condition  is  similar  to  that  of  deep  sleep, 
from  which  the  individual  awakens  without  the  slightest 
recollection  of  anything  that  has  occurred.     In  the  severe 


HYSTEEO-EPILEPSY. 


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224  FUNCTIO]SrAL    NERVOUS    DISORDERS. 

cases  there  may  be  a  complete  suspension  of  consciousness 
and  volition,  but  in  the  more  common  type,  which  occurs 
vrith  considerable  frequency,  volition  is  usuallj'  sup- 
pressed, while  consciousness  remains  unimpaired.  Severe 
and  prolonged  attacks  of  this  disease,  lasting  for  many 
days,  are  uncommon.  There  are  states  allied  to  catalepsy 
in  which  sensation  only  is  abolished,  the  power  of  motion 
remaining  perfect.  Catalepsy  has  been  frequently  mis- 
taken for  death  itself;  as  a  rule,  the  breathing  is  light  and 
almost  imperceptible,  although  in  some  cases  which  I  have 
seen  it  was  of  a  stertorous  character.  The  skin  is  of  a 
pale  and  death-like  hue;  the  pulse  is  usually  feeble  and 
frequently  accelerated. 

This  condition  is  not  very  rare  when  disease  of  the  brain 
is  present,  and  it  often  coexists  with  insanity.  It  is  cer- 
tainly a  curious  and  interesting  affection,  and,  being  of  a 
rather  marvellous  type,  is  a  subject  of  great  interest  to 
non-medical  readers. 

The  daily  newspapers  frequently  publish  cases  of  cata- 
lepsy or  trance;  the  result  of  reading  the  articles  is  to 
excite  a  dread  of  being  buried  alive,  and  is  thus  the  cause 
of  considerable  mental  suffering  among  weak-minded  peo- 
ple. As  undoubted  cases  of  this  horrible  occurrence  are 
upon  record,  it  is  essential  that  the  condition  should  re- 
ceive from  the  physician  the  study  and  investigation 
which  it  deserves. 

The  following  case  of  trance  was  described  to  me  by  a 
patient,  an  exceedingly  intelligent  woman  and  a  close 
observer,  who  was  an  eye-witness  of  the  occurrence. 

Case  I. — Mrs.  K.  L.  is  48  years  old,  and  extremely  ner- 
vous; she  has  had  one  child.  Her  husband,  a  sea  captain, 
causes  her  a  great  deal  of  worry  on  account  of  his  vicious 
behavior.     Her  affection  for  him  is  very  great,  but  he  does 


HTSTEEO-EPILEPST.  225 

not  return  it.  She  is  tall  and  rather  emaciated,  has  dark 
hair  and  gray  eyes,  and  a  sallow  complexion.  For  the  past 
five  years,  she  has  been  having  so-called  "fainting-fits." 
These  come  on  suddenly,  and  she  usually  comes  out  of 
them  in  from  half  an  hour  to  an  hour.  On  one  occasion, 
exhausted  from  the  exertion  of  ironing  a  dress  for  her 
daughter  of  12  years,  she  fell  into  one  of  these  fits,  and 
remained  without  motion  from  7  p.m.  until  10  p.m.  the 
next  night — near  twenty-seven  hours.  She  was  cold  and 
seemed  to  be  perfectly  lifeless.  Those  in  attendance  ap- 
plied a  hand  mirror  to  her  mouth  to  see  if  there  was  any 
respiration  to  deposit  moisture  upon  it,  but  there  seemed 
to  be  none.  After  this  incomplete  test  the  neighbors  pro- 
nounced her  dead  and  proceeded  to  make  her  shroud. 
Dr.  John  Osborne  was  called,  and  said  that  she  was  liv- 
ing. He  requested  to  be  called  again  if  there  were  any 
change  in  her  condition.  During  these  twenty-seven 
hours,  Mrs.  L.  says  that  she  was  conscious  of  every  word 
that  was  spoken,  and  of  course  heard  the  remarks  about 
her  supposed  death.  She  said  her  only  hope  was  that 
when  her  child  returned  from  the  entertainment  to  which 
she  had  gone,  she  would  in  her  fright  throw  herself  upon 
her  neck  and  awaken  her.  She  was  unable  to  see,  but 
hearing  was  normal.  Attempts  were  made  to  administer 
food,  but  she  could  not  swallow.  She  claims  to  have  been 
entirely  conscious  the  whole  time,  and  must  have  endured 
agonies  of  mental  torture.  A  pricking  sensation  in  the 
lower  limbs  ushered  in  a  gradual  return  to  a  waking  state. 
The  attack  was  followed  by  shivering.  She  said  that  she 
was  quite  convinced  that  they  would  bury  her  alive.  She 
thought  that  the  attack  had  some  connection  with  the 
menopause.     She  lived  for  fifteen  years  after  this  incident. 

In  cases  of  apparent  death  in  the  state  of  catalepsy, 
every  effort  should  be  made  to  resuscitate  the  patient  by 
means  of  galvanism,  transfusion,  etc. ;  and  in  many  cases 
where  death  seems  to  have  occurred  beyond  a  doubt  our 

efforts  will  be  crowned  with  success.     Decomposition  is 

15 


226  FUNCTIONAL   NERVOUS    DISOEDERS. 

the  only  positive,  irrefutable  evidence  of  death.  The  vital 
spark  may  be  latent,  only  needing  the  application  of  fara- 
dism  or  galvanism,  or  both,  to  fan  it  again  into  activity. 
There  is  no  doubt  whatever  that  many  persons  have  been 
buried  alive  in  a  state  of  catalepsy  who  might  have  been 
restored  to  life,  had  the  proper  means  been  taken  for  their 
reanimation. 

In  my  opinion,  the  efforts  to  resuscitate  the  apparently 
dead  in  this  condition  should  end  only  with  the  appear- 
ance of  evidences  of  commencing  decomposition. 

Attacks  of  trance  frequently  alternate  with  attacks  of 
hystero-epilepsy.  They  are  undoubtedly  dependent  upon 
some  form  of  vasomotor  disturbance  in  the  cerebral  circu- 
lation. In  these  cases,  the  pulse  in  the  beginning  of  the 
attack  is  extremely  rapid  and  irregular;  afterward  it 
becomes  less  frequent  and  more  feeble,  dropping  down  to 
40,  and  finally  being  quite  imperceptible  at  the  wrist. 
In  some  cases  even  the  heart  cannot  be  heard  to  beat  with- 
out careful  auscultation  with  the  stethoscope.  Under  such 
conditions  a  person  might  easily  be  buried  alive.  In  the 
cases  under  discussion,  neither  respiration  nor  circulation 
is  perceptible,  the  patient  frequently  Ij^ing  in  this  con- 
dition for  hours  or  even  days. 

The  onset  of  catalepsy  is  very  rarely  sudden ;  there  are 
usually  some  premonitory  symptoms,  e.g.,  headache,  in- 
somnia, nervous  irritability  or  excitement,  illusions,  and 
sometimes  convulsions  of  a  mild  character.  At  the  time 
of  the  seizure  the  entire  muscular  sj'stem  is  affected  with 
a  sudden  rigidity.  Cases  are  rare  in  which  only  certain 
limbs  are  affected.  The  muscles  for  a  time  are  fixed,  and 
the  limbs  can  be  neither  flexed  nor  extended,  the  patient 
remaining  in  the  exact  position  she  was  in  at  the  time  of 
the  attack.     The  eyes  are  often  directed  upward,  having 


HYSTERO-EPILEPST.  237 

a  wild,  staring  expression.  Sometimes  the  lids  are  closed, 
but  usually  they  remain  open.  After  a  period  of  fixed 
rigidity,  the  muscles  assume  the  condition  known  as 
"  waxen  flexibility" ;  the  limbs  or  fingers  can  be  placed  in 
any,  even  the  most  abnormal,  position,  and  will  remain  as 
placed  for  a  considerable  length  of  time.  A  patient  can 
even  be  stood  upright  on  his  feet,  and  with  the  very  slight- 
est support  will  retain  that  position. 

The  patient  upon  recovery  has  no  recollection  of  what 
has  occurred  during  the  attack,  and  in  some  severe  cases 
anaesthesia  and  analgesia  are  present;  in  others,  however, 
the  patient  retains  sensibility  to  a  certain  extent,  but  reflex 
movement  is  absent ;  the  nostrils  or  the  soles  of  the  feet 
may  be  tickled  without  eliciting  any  manifestations  of 
sensation.  In  some  cases  the  conjunctiva  may  retain  its 
sensibility.  The  functions  of  the  bladder  and  bowels  are 
performed  slowly;  a  piece  of  food  introduced  into  the 
pharynx  is  usually  swallowed  without  difficulty.  In  some 
cases,  after  the  power  of  voluntary  motion  has  been  recov- 
ered, the  "  waxen  flexibility"  of  the  limbs  may  still  persist. 

Some  patients  while  in  the  cataleptic  state  have  a  per- 
fect consciousness  of  everything  that  is  transpiring  around 
them;  others  have  a  partial  and  indistinct  idea  of  what  is 
happening;  while  others  again  are  totally  oblivious  to 
their  surroundings  and  their  loss  of  consciousness  is  com- 
plete. The  recovery  from  one  of  these  attacks  is  always 
sudden;  the  patient  starts  up  with  a  yawn  or  a  sigh,  as  if 
from  a  deep  sleep. 

The  paroxysms,  as  a  rule,  at  first  occur  without  any 
regularity.  After  the  initial  attacks  the  patients  are  usu- 
ally in  good  health,  but  after  the  occurrence  of  many  and 
severe  seizures  they  suffer  for  some  time  from  hysterical 
symptoms,  headache,  vertigo,  and  general  prostration. 


228  PUN"CTioi«rAL  kervous  disorders.    • 

The  causes  of  catalepsy  are  very  seldom  local,  but  affect 
the  entire  sj^stem.  Nervous,  hysterical  women  are  the 
most  common  subjects.  Violent  emotions,  mental  excite- 
ment, impaired  diges- 
tion, disordered  menstru- 
ation, nervous  exhaus- 
tion, and  similar  causes 
are  the  exciting  factors 
of  this  condition.  The 
seizures  are  most  common 
in  young  adults,  about  the 
beginning  of  the  period 
of  active  uterine  life,  or 
in  those  more  advanced 
in  life  who  have  uterine 
disease. 

Dr.  Gooch  relates  the 
following  case,  which  is 
a  good  example  of  the 
disorder : 


The  patient  was  a 
woman,  the  victim  of 
melancholi  a.  Shortly 
after  parturition  she  was 
seized  with  the  cataleptic 
attack,  and  presented 
the  following  appearan- 
ces: 

Fig.  26.— Catalepsy  in  Melancholia.    Patient         She   WaS  lying     in    bed 
keeps  this  position  for  half  an  hour  with-  .  ^ 

out  moving.  motionless  and  apparent- 

ly senseless.  It  was 
thought  the  pupils  of  her  eyes  were  dilated,  and  some 
apprehensions  were  entertained  of  effusion  on  the  brain; 
but  on  examining  them  closely  it  was  found  they  read- 


HYSTERO-EPILEPST.  229 

ily  contracted  when  the  light  fell  upon  them.  Her 
eyes  were  open,  but  there  was  no  rising  of  the  chest, 
no  movement  of  the  nostril,  no  appearance  of  respiration. 
The  only  signs  of  life  were  warmth  and  a  pulse  which  was 
120,  and  weak.  Her  faeces  and  urine  had  been  voided  in 
bed.  In  attempting  to  rouse  her  from  this  senseless  state 
the  trunk  of  the  body  was  lifted  up  and  placed  so  far  back 
as  to  form  an  obtuse  angle  with  the  lower  extremities,  and 
in  this  posture,  with  nothing  to  support  her,  she  continued 
sitting  for  many  minutes.  One  arm  was  now  raised,  and 
then  the  other,  and  in  the  posture  they  were  placed  they 
remained.  It  was  a  curious  sight  to  see  her  sitting  up 
staring  lifelessly,  her  arms  outstretched,  yet  without  any 
visible  signs  of  animation.  She  was  very  thin  and  pallid, 
and  looked  like  a  corpse  that  had  been  propped  up  and 
stiffened  in  that  attitude.  She  was  now  taken  out  of  bed 
and  placed  upright,  and  attempts  were  made  to  rouse  her 
by  calling  loudly  in  her  ears,  but  in  vain ;  she  stood  up, 
indeed,  but  as  inanimate  as  a  statue.  The  slightest  push 
put  her  off  her  balance,  and  she  made  no  exertion  to  regain 
it,  and  would  have  fallen  had  she  not  been  caught.  She 
went  into  this  state  three  times ;  the  first  lasted  fourteen 
hours,  the  second  twelve  hours,  and  the  third  nine  hours, 
with  waking  intervals  of  three  days  after  the  first  fit,  and 
of  one  day  after  the  second;  after  this  time  the  disease 
assumed  the  ordinary  form  of  melancliolia. 

The  case  of  M.  C,  which  follows,  shows  the  effect  of 
malarial  fever,  together  with  exhausting  uterine  disease, 
in  the  jDroduction  of  the  lethargic  or  trance  state.  Exces- 
sive leucorrhoea  in  frail,  delicate  women  is  not  only  pro- 
ductive of  profound  nervous  disturbances  and  physical 
exhaustion,  but,  in  a  great  number  of  young  women,  is 
the  principal  causative  factor  in  the  production  of  phthisis. 
The  leucorrhoea  in  these  cases  is  usually  secondary  to  the 
maldigestion,  although  sometimes  it  precedes  it.  The 
case  especially  shows  the  well-known  value  of  Fowler's 


330  FUNCTIONAL   NERVOUS    DISORDERS. 

solution  as  a  tonic  in  these  conditions  of  exhaustion  of  the 
nervous  system. 

Case  II. — Lethargy,  Trance,  Recurrent  Orgasm  De- 
pendent upon  Oophoritis,  Endocervicitis,  and  Leucor- 
rhcea. — Miss  M.  C,  teacher,  age  about  26,  is  frail  and  very 
delicate.  A  few  months  previous  to  her  first  menses, 
which  commenced  at  14,  this  patient  had  her  first  attack, 
during  which  she  could  neither  speak  nor  move,  but  was 
perfectly  conscious.  In  1873,  she  had  a  severe  attack  of 
chills  and  fever  and  has  since  suffered  more  or  less  from 
malaria.  She  has  always  been  a  heavy  sleeper,  and  al- 
though she  has  done  all  she  could  to  combat  her  drowsi- 
ness, it  would  overcome  her,  no  matter  what  position  she. 
would  take.  She  has  slept  standing,  sitting,  and  kneeling ; 
her  head  during  this  time  would  seem  of  a  ton  weight. 
In  1879  she  became  very  nervous,  and  for  two  or  three 
months  she  slept  from  twelve  to  fourteen  hours  each  day, 
and  even  then  she  still  felt  drowsy,  but  her  head  was  much 
relieved.  Part  of  the  time  she  had  a  feeling  as  if  an  iron 
band  were  tightly  pressing  the  crown  of  the  head.  Leu- 
corrhoea  then  commenced,  and  has  continued  more  or  less 
ever  since.  In  the  summer  of  1886  she  was  very  weak, 
and  afternoons  while  resting,  and  oftentimes  before  going 
to  sleep  at  night,  she  would  have  the  following  sensations : 
At  first  she  would  lose  all  power  of  feeling  in  the  hands 
and  feet,  until  gradually  the  whole  body  became  numb;  at 
the  same  time  she  had  the  hallucination  that  she  was  as- 
suming immense  proportions,  each  tooth  seeming  to  ex- 
pand, and  she  could  feel  the  nerve  of  each  separate  one 
throbbing.  Very  often  at  this  stage  she  would  jump  up  in 
great  fright,  her  heart  beating  violently  and  the  whole 
body  trembling;  at  others,  after  a  while  she  would  fall 
into  a  heavy  sleep.  At  other  times  on  awakening  she  was 
conscious  of  all  that  happened  around  her,  but  was  utterly 
unable  to  move  or  speak.  She  has  recognized  persons 
entering  the  room,  heard  what  they  said,  and  has  done  her 
utmost  to  let  them  know  she  was  awake,  but  could  not 


HTSTERO-EPILEPST.  231 

move  a  voluntary  muscle  of  her  body.  She  has,  at  such 
times,  tried  to  move  a  finger  or  a  toe  or  an  eyelid,  but  could 
not  succeed.  She  has  sometimes  been  an  hour  trying  to 
rouse  herself  out  of  this  state,  and  when  at  last  she  suc- 
ceeded, the  efforts  made  would  leave  her  very  much  ex- 
hausted and  bring  on  a  severe  palpitation  of  the  heart. 
She  had  these  attacks  very  often  during  the  summer  and 
autumn  of  1886,  but  was  not  seriously  ill  until  December, 
when  I  first  saw  her.  She  was  then  very  feeble,  but  under 
treatment  improved  greatly.  In  April,  1887,  she  began 
to  have  recurrent  orgasms,  which  occurred  regularly  ten 
days  after  menstruation,  continuing  daily  for  a  Aveek. 
These  lasted  until  July,  and  caused  a  return  of  the  cata- 
leptoid  state.  On  examination,  the  uterus  was  found  ten- 
der and  eroded,  with  tenderness  and  enlargement  of  both 
ovaries.  She  was  given  phosphorus  pills,  Fowler's  solu- 
tion in  large  doses,  and  fly  blisters  were  applied  over  the 
ovarian  region.  Electricity  (faradic  current)  increased 
the  number  of  orgasms.  Fowler's  solution  produced  great 
improvement,  and  she  now  enjoys  good  health. 

Case  III. — Trance  or  Cataleptoid  State;  Ovarian 
Hyperoesiliesia,  Cervix  Eroded^  Dysmenorrhoea,  Leu- 
corrhcea. — Miss  A.  B.,  age  23,  has  severe  headaches 
which  come  on  before  the  menses ;  very  severe  pain  in  the 
left  ovarian  region  comes  on  with  the  menstral  flow.  She 
has  leucorrhoea,  and  on  examination  the  pelvic  peritoneal 
plane  is  found  to  be  very  sensitive ;  the  cervix  is  eroded. 
She  is  at  times  very  hysterical.  She  has  had  an  attack 
of  severe  pain  in  the  epigastrium  during  which  she  was 
cataleptoid;  this  persisted  for  a  considerable  time.  Under 
treatment  by  curative  exercise,  hydrotherapy,  and  massage 
she  made  a  good  recovery. 

Excessive  fright  is  a  common  cause  of  severe  functional 
nervous  disease,  as  is  also  a  lack  of  judicious  restraint 
upon  the  emotions.     Jealousy,  as  in  the  following  case,  is 


232  FUNCTIONAL    NEKVOUS    DISOEDERS. 

a  common  cause  of  hysterical  manifestations  in  those  who 
are  the  victims  of  defective  hygiene. 

Case  IV. — Hyster^o- Catalepsy  ;  Trance,  Ovarian 
Hyper cesthesia,  Menorrhagia. — Miss  L.  L.,  age  18. 
Her  father  is  dead,  her  mother  a  drunkard  and  quarrel- 
some. January  10th,  1888.  Her  first  attack  was  six 
months  ago  from  a  fright,  some  one  having  placed  a 
"stuffed  man"  in  her  bed.  This  attack  lasted  three  hours 
and  was  followed  by  slighter  attacks.  A  month  ago  she 
had  another  severe  attack,  has  been  yqvj  nervous,  and  is 
jealous  of  her  lover.  She  has  had  a  severe  cold.  At  2 
P.M.  to-da}',  she  went  off  into  a  "sort  of  faint";  there 
were  no  twitchings  nor  convulsions.  When  I  saw  her, 
her  pupils  were  contracted  to  pinhead  size.  She  has 
general  cutaneous  anaesthesia,  responding  but  slightl}'  to 
severe  tests.  Pulse  is  jerky  and  irregular,  limbs  in  a 
cataleptoid  state,  skin  cold,  and  she  looks  like  death, 
January  11th,  her  condition  was  unchanged.  Suddenl}^ 
she  gives  a  jerk,  throws  both  arms  backward  and  extends 
them,  and  goes  into  an  ecstatic  condition.  During  the 
attack  she  has  very  marked  internal  strabismus  and  is 
cataleptoid.  Later  I  learned  that  the  bowels  have  been 
constipated  for  five  days,  and  that  she  has  pain  in  the 
back  of  the  head  and  prsecordial  region.  She  has  had 
dysmenorrhoea  ever  since  the  function  of  menstruation 
was  established.  During  the  last  month  she  has  men- 
struated twice  and  very  profusely.  There  is  ovarian 
hypereesthesia. 

Mistakes  in  diagnosis  are  of  course  frequent,  but  the 
error  made  in  the  following  case  should  serve  to  put  us  all 
upon  our  guard  against  classifying  simple  functional  reflex 
disorders  as  cases  of  profound  local  disease.  The  case  also 
shows  what  has  been  noted  in  other  instances,  that  not 
only  a  condition  of  ancemia  but  one  of  supposed  cerebral 
hypersemia  may  precede  the  cataleptoid  state.     A  sensa- 


HTSTERO-EPILEPST.  233 

tion  as  of  hammering  at  the  vertex,  joined  to  excessive 
redness  of  the  face,  has  been  noted  in  many  patients  suffer- 
ing from  various  functional  nervous  disorders. 

Case  Y. — Trance  of  Cataleptoid  State  j  Sjnnal  Irri- 
tation, Globus  Hystericus,  Endometritis,  Leucorrlicea, 
Retroflexion,  Menstruation  Never  Regular. — Miss  M. 
N.,  single,  age  26,  menstruated  first  at  20;  at  17  she  had  a 
discharge  of  thick,  yellowish  leucorrhoea,  which  continued 
a  year  and  six  months;  she  was  kept  in  bed  thirteen 
months  by  a  physician  (for  supposed  suppurating  spinal 
disease  discharging  by  the  vagina).  The  spine  is  tender 
from  the  middle  dorsal  region  to  the  coccyx,  this  tender- 
ness having  been  very  marked  at  the  time  when  the  phj^si- 
cian  ordered  her  to  keep  to  her  bed.  At  the  time  when 
the  menses  were  appearing,  she  had  an  attack  of  vicarious 
hemorrhage  from  the  stomach.  Menstruation  is  never 
regular.  She  has  pain  in  the  temples  and  neuralgic  head- 
ache; the  skin  is  sensitive.  There  is  a  bright  flush  on 
both  malar  bones,  and  the  least  excitement  gives  her  a 
momentary  but  intense  blush.  The  tongue  is  coated 
white;  pulse  100,  strong  and  full;  stomach  swollen.  She 
has  pain  in  the  left  ovarian  region,  extending  to  the  back. 
Since  the  age  of  18  she  has  had  attacks  in  which  she  was 
sleepless  and  frightened  at  night.  The  attacks  came,  both 
when  asleep  and  awake,  with  a  sensation  of  compression 
in  the  brain,  the  face  being  at  this  time  xevj  red,  and 
were  followed  by  a  creeping  sensation  beginning  at  the 
toes  and  fingers  and  going  to  the  head ;  then  ensued  a  cata- 
leptoid state.  She  could  moan  but  could  do  nothing  else — 
could  stir  neither  hands  nor  feet.  To-daj',  May  20th,  1889, 
the  globus  hystericus  "  is  one  minute  in  the  throat,  and  the 
next  back  again  to  the  left  ovarian  region."  She  has  cold 
and  clammj'  feet  and  hands.  Appetite  is  poor,  and  she 
is  easily  nauseated.  On  examination  I  find  endometritis 
and  retroflexion. 

Agonizing  and  unbearable  pain,  not  only  in  the  ovarian 
but  in  the  epigastric  region,  is  a  very  common,  if  not  the 


334  EUNCTIOKAL   NERVOUS    DISORDERS. 

most  frequent,  exciting  cause  of  both  hystero-epilepsy  and 
of  the  cataleptoid  state. 

Case  VI. — Trance  or  Cataleptoid  State;  Ovarian 
Hyper cesthesia,  3Iigraine,  Palpitations,  Lacerated  Cer- 
vix, Granulations. — Mrs.  L.  is  a  widow,  age  30.  Her 
attack  of  hystero-cataleptoid  state  comes  on  from  agoniz- 
ing pain  in  the  ovarian  region  before  menstruation ;  she  is 
constantly  nauseated,  and  is  very  nervous.  The  attack 
lasts  but  a  few  minutes;  she  finds  it  impossible  to  move 
or  speak,  "is  cold  as  ice,"  and  sweats  profusely.  It  is 
sometimes  followed  by  extreme  prostration.  She  has  mi- 
graine. Examination  reveals  laceration  of  the  cervix  on 
the  left  side,  with  granulations. 

Case  VII. — Mrs.  K.,  33  years  of  age,  is  a  nullipara,  al- 
though married  for  a  number  of  years.  December  10th, 
1892,  she  complained  of  feeling  very  badly;  her  head  was 
sore  from  neuralgia,  she  had  no  appetite,  her  stomach  was 
distended,  and  her  tongue  was  heavily  coated.  I  have 
just  succeeded  in  relieving  her  of  a  tapeworm  in  the  fol- 
lowing manner:  I  prescribed  a  mixture  containing  a 
drachm  of  kretol  to  four  ounces  of  water,  of  which  she 
took  a  dessertspoonful  every  two  hours.  This  was  fol- 
lowed by  a  large  dose  of  castor  oil,  and  within  an  hour  the 
worm  was  brought  away  complete.  Before  this  she  had 
been  suffering  much  with  "bloating"  of  the  belly  and 
pains  in  the  legs,  and  had  had  grinding  of  the  teeth  at 
night. 

The  excessive  evacuations  produced  by  the  castor  oil 
made  her  feel  very  weak,  and  while  sleeping  the  trance  or 
cataleptoid  state  came  on.  She  heard  the  letter  carrier 
ring  the  door  bell,  but  could  not  get  up  to  answer  it.  She 
knew  where  she  was  and  tried  very  hard  to  move,  but 
found  it  impossible.  There  was  "  no  dream  about  it" ;  it 
was  simply  that  she  was  powerless  to  move.  When  she 
finally  came  out  of  this  state,  her  feet  "felt  as  heavy  as 
lead,"  and  she  could  not  be  induced  to  lie  down  again  for 
fear  of  a  return  of  the  attack. 


HYSTERO-EPILEPSY.  235 

In  her  case,  the  condition  of  the  digestive  organs  and 
the  anaemia  present,  together  with  tlie  excessive  drain 
upon  her  system  from  the  energetic  action  of  the  oil,  were 
sufficient  to  induce  this  cataleptoid  attack. 

The  following  case  illustrates  a  mild  form  of  trance  or 
the  cataleptoid  state,  or  an  allied  condition. 

Case  VIII.— Mary  G.,  27  years  of  age.  The  disease 
began  with  great  mental  worry.  She  is  now  extremely 
nervous.  She  has  had  three  attacks  in  which  her  legs 
"  gave  way" ;  she  becomes  suddenly  weak  and  numb  all 
over  the  body.  These  attacks  do  not  last  very  long ;  they 
are  not  the  same  as  attacks  of  syncope,  but  consist  of  a 
sudden  numbness  or  powerlessness.  At  the  present  mo- 
ment, although  her  appetite  is  fair  and  her  color  good,  her 
feet  and  hands  are  numb,  and  she  frequently  experiences 
creeping  sensations  in  the  extremities.  The  attacks  come 
on  with  a  severe  nervous  chill,  and  are  followed  by  hys- 
terical trembling. 

Under  dietetic  and  medical  treatment  she  recovered. 

The  following  case  of  cataleptoid  state  illustrates  the 
intimate  connection  between  the  digestive  and  nervous 
systems,  and  the  dependence  of  nervous  manifestations 
upon  malassimilation,  these  conditions  resulting  from 
overwork  and  bad  food. 

Case  IX. — Agnes  Gr.,  an  anaemic  young  girl,  suffers 
severely  with  frontal  headaches,  which  come  on  three 
days  before  menstruation.  The  face  during  this  time  feels 
cold,  and  there  is  a  sensation  of  coldness  on  the  vertex  as 
if  it  had  been  "  wet  with  cold  water;" 

I  frequently  find  that  the  headaches  of  ansemia  are  also 
present  immediately  before  menstruation.  In  this  case 
there  were  also  severe  cramps  of  anaemic  dysmenorrhoea 
coming  on  immediately  after  the  appearance  of  the  flow. 
The  pain  is  most  severe  in  the  left  ovarian  region  and  in 


236  FUNCTIOIS^AL   NERVOUS    DISORDEES. 

the  back ;  her  feet  "  are  never  warm."  On  vaginal  exami- 
nation I  find  considerable  leucorrhoea  present,  and  the 
peritoneal  plane  is  considerably  inflamed  and  quite  sensi- 
tive. She  consults  me  principally  for  severe  attacks  of 
gastric  pain,  during  which  she  completely  loses  control  of 
herself,  and  can  neither  speak  nor  move.  This  state  lasts 
for  the  space  of  twenty  minutes  or  more.  After  a  time 
she  gradually  recovers  both  motion  and  sensation.  Her 
digestion  is  markedly  embarrassed,  as  the  result  of  over- 
work and  a  bad  selection  of  food.  She  takes  strong  tea 
in  large  amounts. 

Ecstasy. 

Ecstasy  is  a  state  of  the  system  in  which  the  mind  is 
apparently  absorbed  by  some  dominant  idea,  the  patients 
being  at  the  time  totally  insensible  to  their  surroundings. 
The  condition  is  somewhat  similar  to  that  of  catalepsy",  and 
is  by  many  authors  considered  to  be  identical  with  trance, 
of  which  it  is  probably  a  form.  It  is  frequently  present 
after  a  hystero-epileptic  attack.  The  visual  hallucina- 
tions which  often  occur  are  the  most  remarkable  features 
of  this  condition.  The  mind  is  active  and  the  visions  are 
remembered  after  the  attacks  are  over.  In  catalepsy, 
however,  there  is  usually  total  oblivion  during  the  attack. 
At  this  time  the  pulse  remains  normal.  Attacks  are  often 
epidemic  during  periods  of  religious  excitement,  when 
they  usually  take  the  simpler  forms  of  the  malady.  They 
are  quite  common  at  negro  revivals  and  among  the  primi- 
tive Methodists.  The  "convulsionnaires"  were,  a  set  of 
religious  ecstatics  existing  before  the  French  revolution. 
The  Dervishes  in  Egypt,  and  the  Jumpers  of  eastern 
Maine  and  New  York,  are  also  specimens  of  this  class  of 
religious  contortionists,  who  suffer  from  a  mild  form  of 
mania.     The  disease  is  communicable  by  imitation,  espe- 


HYSTERO-EPILEPST.  237 

cially  among  the  ignorant.  "Mocking  is  catching,"  not 
only  among  children  but  among  adults,  and  especially  is 
this  so  when  the  disease  is  epidemic  and  its  manifestations 
assume  the  more  noisy  and  ridiculous  forms.  This  was 
seen  in  the  spasmodic  epidemics  of  the  Middle  Ages.  The 
dancing-mania  lasted  for  a  period  of  one  hundred  and  fifty 
years  in  Germany.  Many  of  these  ecstatic  cranks  pretend 
to  find  in  the  Bible  examples  to  justify  their  capers. 

Among  the  exciting  causes  of  ecstasy,  emotional  dis- 
turbances, especially  of  a  perverted  religious  character, 
are  the  most  prominent. 

Severe  and  prompt  measures  should  be  used  to  suppress 
these  epidemics.  At  one  time,  in  the  Infirmary  for  Chil- 
dren and  Young  Girls,  I  had  an  epidemic  of  chorea  in 
which  about  a  dozen  children  were  affected.  Isolation, 
with  but  little  other  treatment  except  Fowler's  solu- 
tion, was  suflQcient  to  cause  its  almost  immediate  disap- 
pearance. 

Somnambulism. 

Somnambulism  is  frequently  present  in  cases  of  hystero- 
epilepsy  as  a  part  of  the  attack,  following  the  more  pro- 
found disturbances.  It  seems  to  be  a  very  mild  form  of 
delirium  or  cerebral  irritation.  The  mildest  type  consists 
simply  of  talking  during  sleep,  but  in  the  more  severe 
forms  the  patient  leaves  the  bed  and  walks  about,  and  if 
the  cerebral  excitement  be  still  more  marked  he  even  goes 
into  the  street  and  walks  long  distances.  It  is  quite  com- 
mon in  nervous  and  excitable  children  who  are  fed  freely 
upon  indigestible  food.  Adults  who  are  subject  to  it  are 
usually  such  as  are  suffering  from  profound  mental  anx- 
iety, or  who  are  engaged  in  exhausting  mental  occupation. 

Upon  awaking  in  the  morning  there  may  sometimes  be 


238  FUNCTIONAL   NERVOUS    DISORDERS. 

a  faint  recollection  of  what  has  occurred,  as  the  disease  is 
really  only  a  very  pronounced  form  of  dreaming  of  which 
movement  forms  a  part.  A  good  description  of  a  typical 
case  is  given  by  Shakespeare  in  his  portrayal  of  Lady 
Macbeth. 

In  the  treatment  special  attention  should  be  given  to 
diet  and  the  condition  of  the  digestive  organs.  The  men- 
tal state  previous  to  retiring  should  be  calm.  Precautions 
should  be  taken  to  have  the  windows  of  the  somnambu- 
list's room  so  fixed  that  he  cannot  walk  or  fall  out  of  them, 
as  many  have  received  serious  barm  in  this  manner. 

Cerebral  excitement  resulting  from  excess  of  the  emo- 
tions, or  from  intellectual  exertion,  are  causative  factors 
in  this  disease,  and  should  be  avoided.  Overloading  and 
embarrassing  the  digestive  organs  with  an  excess  of  greasy 
and  improperly  prepared  food  tends  to  disturbance  of  the 
cerebral  circulation  by  causing  hyperemia,  with  somnam- 
bulism as  a  result.  In  some  young  patients  somnambu- 
lism tends  to  become  a  habit.  It  is  well  to  sleep  with  the 
head  well  raised.  Only  light  meals  of  easily  digested  food 
should  be  taken  several  hours  before  retiring,  and  fully  an 
hour  before  a  glass  of  hot  water  should  be  drunk  to  re- 
move gastro-intestinal  irritations  and  act  as  a  sedative  to 
the  digestive  tract.  When  the  hot  water  is  taken  immedi- 
ately before  retiring  it  acts  as  a  stimulant  to  the  circula- 
tion and  induces  cerebral  hypersemia.  There  are  some 
patients  who  require  a  little  food,  such  as  a  cracker  or  a 
piece  of  toast  and  a  small  glass  of  milk  very  shortly  be- 
fore retiring,  and  who  cannot  sleep  without  it.  When 
such  patients  are  subject  to  somnambulism,  the  greatest 
care  should  be  exercised  that  only  the  smallest  amount  of 
food  is  taken,  as  indis:estion  predisposes  to  cerebral  con- 
gestion, which  is  already  present  in  these  cases. 


HYSTEEO-EPILEPSY.  239 

One  method  of  arresting  the  attack  of  somnambulism  is 
to  place  a  slab  of  marble,  a  piece  of  sheet-iron,  zinc,  oil- 
cloth, or  any  such  cold  body  beside  the  bed,  in  such  a 
position  that  the  sleepwalker  must  first  step  upon  it.  As 
a  rule,  he  will  go  no  further ;  the  cold  thrill  sent  through 
him  will  partially  awaken  him,  and  he  will  return  to  bed. 

Insomnia. 

Cerebral  hypersemia  is  the  most  common  factor  in  the 
production  of  wakefulness.  An  excited  or  active  state  of 
the  brain,  with  an  increased  amount  of  blood  in  its  tissues, 
are  the  conditions  usually  present?  The  removal  of  the 
irritation  and  hypersemia  is  therefore  essential  before  sleep 
can  be  procured.  After  great  mental  strain  or  great  phys- 
ical effort,  insomnia  usually  follows,  due  probably  in  these 
cases  to  hypersemia  of  the  brain  as  a  result  of  weakened 
heart  action.  Where  there  is  an  exhaustion  of  the  vaso- 
motor nerves,  there  is  a  deficient  tone  in  the  cerebral  ves- 
sels, and  a  passive  hypersemia  results. 

Cerebral  anaemia  is,  as  a  rule,  present  when  the  patient 
is  drowsy,  although  in  diseased  states  wakefulness  may 
be  produced  by  it.  Insomnia  should  in  many  cases  be 
looked  upon  as  a  neurosis  dependent  upon  disease  of  the 
liver  and  other  organs.  Patients  suffering  from  severe 
malarial  fever  seldom  sleep  well,  and  in  these  cases  the 
hypnotic  action  of  quinine  is  marked,  in  addition  .to  its 
other  valuable  properties.  In  conditions  of  exhausted 
nerve  force  with  insomnia,  the  stimulation  arising  from 
a  full  meal  often  causes  the  patient  to  become  drowsy  and 
sink  into  a  sound  sleep.  The  irrita.tion  of  an  empty  stom- 
ach and  the  consequent  cerebral  hypersemia  cause  much 
wakefulness.     It  is  a  custom  with  many  persons  to  take  a 


240  FUJSrCTIONAL   NEKVOUS   DISOEDERS. 

sandwich  and  a  glass  of  light  beer  before  retiring,  and  in 
fact  anything  which  stimulates  the  solar  plexus  of  the 
sympathetic  in  these  cases  has  a  soporific  action.  I  do 
not,  however,  consider  this  to  be  a  good  practice,  as 
digestion  is  always  markedly  slower  and  more  feeble  dur- 
ing sleep.  The  drinking  of  coflPee  and  tea,  even  in  mode- 
ration, will  sometimes,  especially  in  those  unaccustomed 
to  their  use,  prevent  sleep.  Wines,  especially  those  diffi- 
cult of  digestion,  when  taken  in  moderate  amount,  may 
produce  wakefulness,  but  copious  libations  would  probably 
produce  the  opposite  effect.  Monotonous  sounds  or  the 
reading  of  uninteresting  books  have  a  soporific  influence, 
as  has  the  counting  of  numbers  in  a  chantiag  manner. 
The  monk's  prescription  of  "  telling  the  beads"  is  a  good 
method  of  inducing  sleep,  or  one  may  gaze  fixedly  at  some 
object  upon  the  ceiling.  Winking  for  the  space  of  one  or 
two  minutes  has  been  recommended  among  a  variety  of 
other  measures.  Opium  in  moderate  doses  is  a  useful 
drug,  but  it  should  be  carefully  handled  for  fear  of  caus- 
ing the  opium  habit.  It  should  not  be  given  by  hypoder- 
mic injection  except  for  the  relief  of  very  acute  pain. 
Hyoscyamus,  the  bromides,  belladonna,  and  in  some  cases 
cannabis  indica,  and  alcoholic  beverages  are  useful. 

Choeea. 

Chorea  Minor. — Chorea,  or  the  disease  commonly 
known  as  St.  Vitus'  dance,  is  a  functional  nervous  affec- 
tion which  usually  occurs  in  childhood,  is  quite  often 
met  with  in  young  women,  and  is  found  sometimes  dur- 
ing pregnancy.  Rarely  also  it  may  manifest  itself  at 
the  menopause.  From  the  period  of  the  second  dentition 
until  about  the  age  of  nine  years,  both  sexes  seem  to  be 


HYSTEEO-EPILEPST.  241 

equally  liable,  but  after  that  age,  according  to  Sir  Thomas 
Watson,  females  are  more  prone  to  the  disease  than  males, 
in  the  proportion  of  about  five  to  two. 

This  disorder  is  characterized  by  defects  of  voluntary 
co-ordination,  by  clonic  spasmodic  movements  of  the  vol- 
untary muscles,  and  by  a  certain  degree  of  weakness,  more 
or  less  appoaching  to  paralysis,  in  the  affected  parts.  The 
movements  usually  subside  during  sleep.  They  are  some- 
times unilateral,  the  left  being  the  side  most  frequently 
affected.  This  variety  is  called  hemichorea.  The  pa- 
tients are  usually  anaemic,  the  mind  is  weakened,  and 
there  is  much  irritability  of  temper.  Anaesthesia  is  some- 
times present.  As  the  disease  is  a  neurosis,  there  are  no 
characteristic  anatomical  changes  to  be  found  in  fatal 
cases.  Its  causation  depends  upon  ansemia,  the  result  of 
defective  diet  and  hygiene.  The  exciting  cause  may  be  a 
fright,  or  any  violent  disturbance  of  the  emotions.  It  is 
in  children  often  associated  with  rheumatism. 

Many  remedies  have  been  employed  for  the  relief  of  this 
condition.  I  have  had  the  best  success  with  Fowler's  solu- 
tion in  large  doses.  In  an  epidemic  of  this  disorder  which 
occurred  at  the  Infirmary  for  Children  and  Young  Girls, 
every  case  recovered  under  its  administration  combined 
with  isolation  to  obviate  the  mental  contagion.  It  is 
lauded  by  many  as  a  specific  for  the  disease.  Strychnine, 
iron,  and  opium  have  also  been  used  with  much  benefit,  as 
have  also  the  oxide  of  zinc,  valerian,  camphor,  and  asa- 
foetida.  Chloroform  and  ether  given  internally  are  said 
by  some  to  be  of  advantage  on  account  of  their  antispas- 
modic action.  I  have  had  no  experience  with  them. 
Careful  alimentation  is  of  the  greatest  importance. 

Dr.  Hermann  Nebel,  in   his  classic  monograph,   "The 

Mechanical   Treatment  of    Chorea,    A    Historico-Critical 
16 


242  FUJS^CTIONAL   NERVOUS    DISORDERS. 

Study,"  translated  by  Dr.  L.  Wischnewetzky,  has  com- 
pletely covered  the  subject  and  given  the  best  means  of 
treatment  for  this  affection. 

Chorea  Majo7\ — The  term  chorea  has  been  made  to 
include  almost  all  forms  of  involuntary  movements  in 
which  distinct  spasm  or  a  pronounced  tremor  does  not 
exist — salaam  convulsions,  moving  the  head  back  and 
forth  in  a  half -rotary  manner,  bowing,  bobbing,  and  oscil- 
lating movements.  In  its  severe  type  it  is  a  very  grave 
disorder  and  most  distressing  to  witness,  the  patient  cease- 
lessly tossing  herself  in  all  directions  and  being  kept  in 
bed  only  by  means  of  straps.  Headache,  delirium,  and 
even  coma  are  often  present.  The  digestive  organs  are 
always  more  or  less  involved,  as  indicated  by  anorexia, 
gastralgia,  or  vomiting. 

Chorea  major  has  often  assumed  an  epidemic  character. 
In  1418  an  epidemic  broke  out  in  Strasburg  which  took 
the  form  of  uncontrollable  dancing,  leaping,  and  scream- 
ing. Sometimes  the  epidemics  are  of  a  decidedly  hyster- 
ical type,  characterized  by  fits  of  laughter,  dancing,  crying, 
screaming  and  howling,  associated  with  mental  delusions, 
and  with  eructations.  The  disease  has  been  common  in 
France,  Germany,  and  Italy.  In  England  and  America 
we  have  the  Jumpers  and  Shakers,  victims  of  religious 
enthusiasm.  Many  strange  paroxysms  have  accompanied 
the  disorder  in  France  and  Scotland.  The  body  has  been 
distorted  into  every  conceivable  shape,  and  wild  dancing 
and  leaping  have  been  kept  up  to  the  point  of  absolute 
exhaustion. 


CHAPTER   XXI. 
HEMTCRANIA-rMIGRAINE. 

This  extremely  common  vasomotor  neurosis  is,  in 
women,  usually  excited  by  certain  reflex  disturbances. 
In  some  attacks  there  is  contraction  of  the  arterioles  on 
the  affected  side,  with  consequent  ansemia,  as  shown  by 
pallid  face,  shrunken  eye,  and  dilated  pupil.  At  other 
times  the  opposite  condition  of  the  circulation  prevails; 
there  is  dilatation  of  the  vessels,  with  a  flushed  face,  in- 
jected conjunctivae,  and  contracted  pupils. 

Prof.  Charles  L.  Dana  says  that  this  form  of  neuralgia 
occurs  more  often  in  women  than  men,  in  the  proportion  of 
three  to  one ;  the  attacks  are  most  frequent  in  winter  and 
least  so  in  the  spring.  In  America  the  characteristic  form 
is  the  angeio-spastic  type ;  but  migraine  may  occur  with  but 
little  vascular  change^  and  there  are  nervous  or  sick-head- 
aches which  stand  halfway  between  typical  migraine  and 
ordinary  rheumatic  or  gastric  headaches.  In  most  of  his 
cases  migraine  was  found  to  be  hereditary,  or  at  least  a 
family  disease,  alternating  sometimes  with  other  neuroses, 
especially  asthma  and  other  neuralgias.  Only  two  of  his 
cases  seemed  to  be  due  to  asthenia  and  refractive  errors 
of  the  eye,  and  he  was  not  able  to  convince  himself  of  any 
peculiar  nasal  or  pharyngeal  irritations.  He  adds  that 
the  idea  that  migraine  is  a  disease  of  the  sympathetic 
system  is  one  of  the  old  medical  superstitions  which,  with 
the  old  idea  of  the  sympathetic  system,  ought  to  be  done 

away  with  entirely.     Indeed  it  hardly  deserves  to  be  dis- 

243 


244  FUNCTIONAL   NERVOUS    DISORDERS, 

cussed  with  seriousness.  Migraine  is  a  general  neurosis 
like  epilepsy,  showing  itself  in  nervous  discharges  mainly 
in  the  area  of  the  fifth.  Symptomatically,  therefore,  it  is 
to  be  spoken  of  as  a  form  of  trigeminal  neuralgia  whose 
manifestations  are  strikingly  associated  with  vascular  and 
secretory,  and  sometimes  motor,  visual,  and  auditory 
disturbances. 

In  speaking  of  the  determination  of  reflex  pains  with 
regard  to  the  eye,  he  says  they  are  produced  by  asthenopia, 
of  which  there  are  four  types — refractive,  accommodative, 
muscular,  and  neurasthenic.  "  It  appears  to  be  established 
that  refractive  asthenopia  in  one  eye  may  give  rise  to 
migraine.  The  view  that  nearly  all  migraines  are  due  to 
refractive  errors  or  to  imperfection  in  the  muscular  ap- 
paratus of  the  eye  is  certainly,  in  my  experience,  incor- 
rect. It  is  well  to  remember  that,  while  eye  troubles  may 
cause  neuralgia,  so,  on  the  other  hand,  neuralgias  of  the 
fifth  may  cause  eye  troubles — such  as  blepharospasm, 
mydriasis,  myosis,  and  asthenopia  (Faucheron,  Rec. 
d^Ophthal.,  March,  1881).  Occasionally  eye  irritation 
causes  occipital  or  fronto-occipital  pain,  but  this  does  not 
seem  to  be  the  rule.  Iritis  may  cause  pain  felt  over  one- 
half  of  the  cranium,  like  a  migraine." 

Mallendorf  {Virch.  Arch.,  January,  1868)  states  that  in 
his  opinion  migraine  is  due  to  a  lack  of  energy  in  the 
vasomotor  nerves  of  one  of  the  carotid  arteries,  with  sec- 
ondary relaxation  of  the  vessel  and  increased  flow  of  blood 
to  the  brain.  Hypersensitiveness  of  the  senses,  with 
hypersesthesia  of  the  scalp,  nausea,  and  sometimes  vomit- 
ing, are  the  secondary  symptoms.  Dimness  of  vision  is 
sometimes  present.  Mallendorf  quotes  as  proof  of  his 
theory  the  fact  that  the  pain  is  entirely  stopped  by  com- 
pressing the  carotid  on  the  side  affected,  and  that  when 


HEMICEAXIA — MIGEAIXE.  245 

the  compression  is  removed  the  pain  returns;  also  that 
compression  of  the  carotid  on  the  non-affected  side  in- 
creases the  pain. 

The  subjects  in  whom  we  chiefly  meet  with  migraine 
are  women,  who  from  hysteria  or  anaemia  have  developed 
a  morbid  excitability.  It  is  not  unfrequently  accompanied 
by  vomiting  and  is  a  most  distressing  affection.  Owing 
to  the  changes  which  take  place  at  the  menopause,  migraine 
usually  disappears  at  this  period. 

For  the  treatment  of  migraine  a  variety  of  agents  have 
been  used — bromide  of  potassium  in  large  doses,  valerian- 
ate of  caffeine,  quinine,  Fowler's  solution,  etc.  When 
ansemia  or  chlorosis  is  present,  the  preparations  of  iron 
may  be  administered  with  advantage.  Outdoor  exercise 
and  pure  air  are  most  valuable  adjuncts.  Extract  of 
ergot  has  also  been  recommended,  and  in  certain  forms, 
where  vascular  spasm  is  present,  the  inhalation  of  nitrite 
of  amyl  is  of  service. 

I  do  not  believe,  however,  that  the  administration  of  any 
drug  is  alone  capable  of  effecting  any  permanent  benefi.t 
in  these  cases.  Much  more  satisfactory  results  can  be 
obtained  by  properly  regulated  outdoor  exercise,  curative 
gymnastics,  pure  air,  baths,  especially  sea  bathing,  to- 
gether with  a  properly  ordered  diet  and  manual  treatment. 

I  append  a  few  cases  of  migraine.  In  all  of  them  it 
will  be  seen  that  uterine  disease  played  the  chief  role  as 
an  etiological  factor. 

Mrs.  B.  L.,  age  47,  has  six  children  and  has  had  two 
miscarriages.  She  has  migraine,  always  on  the  third  day 
of  menstruation,  and  night  blindness.  There  is  pain  in 
the  hypogastrium,  and  also,  during  menstruation,  in  the 
back  and  shoulder.     She  does  not  have  leucorrhoea. 

Miss  C,  age  25,  has  had  migraine  and  headaches  for 


246      •  FUiq"CTio]srAL  kervous  disorders. 

five  or  six  years;  they  have  been  more  frequent  the  last 
six  months.  Menstruation  lasts  over  a  week,  and  the  flow 
is  excessive.  She  has  a  thick,  yellowish  leucorrhoea ;  pulse 
is  weak,  appetite  poor.  She  works  hard  sewing  on  furs 
with  a  machine. 

Mrs.  M.,  age  45,  lacerated  cervix,  endometritis. 

Mrs.  L.,  age  30,  endometritis. 

Miss  O.  C,  age  38,  endometritis,  left  ovarian  pain. 

Mrs.  Cr.,  age  20,  endometritis  after  abortion. 

Mrs.  v.,  age  23,  endometritis.     , 

Mrs.  B.,  age  23,  endometritis,  lacerated  cervix. 

Mrs.  T.,  age  43,  menopause. 

Mrs.  B.,  age  24,  endometritis  and  perimetritis,  leucor- 
rhoea. 

Miss  C,  age  25,  menorrhagia,  leucorrhoea. 

Mrs.  B.  L.,  age  47,  dysmenorrhoea,  occurs  on  third  day^ 
also  has  night  blindness. 

Miss  N.  B.,  age  24,  dysmenorrhcBa,  inflammation  of  left 
ovary. 

The  following  case  is  of  interest  because  of  the  alterna- 
tion of  two  opposite  states. 

Miss  B.,  age  26,  while  living  in  the  country  always 
enjoyed  perfect  health.  Since  coming  to  New  York,  two 
years  ago,  she  has  suffered  at  irregular  periods,  at  first  about 
once  in  two  weeks,  now  usually  once  and  sometimes  twice 
a  week,  from  severe  attacks  of  migraine.  In  the  intervals 
between  the  attacks  there  is  not  the  slightest  pain  or  dis- 
turbance. There  are  some  slight  prodormal  symptoms, 
such  as  soreness  of  the  body  and  weariness.  She  awakes 
in  the  morning  suffering  with  the  pain,  which  manifests 
its  greatest  intensity  in  or  just  above  the  eye.  There  is 
no  tenderness  of  the  cervical  ganglia  of  the  sympathetic. 
Nausea  always  accompanies  the  attacks,  which  usually 
last  from  six  to  twelve  hours.  They  are  at  times  of  the 
congestive  and  at  others  of  the  anaemic  type.  When  of 
the  former,  the  side  of  the  face  is  intensely  flushed; 
when  of  the  latter,  there  is  extreme  pallor  of  the  parts 


HEMICEAXIA — MIGEAIXE,  247 

affected.  She  has  an  intense  craving  for  sour  articles  of 
food,  and  takes  large  amounts  of  strong  coffee.  A  care- 
fully regulated  diet  caused  immediate  relief,  which  con- 
tinued so  long  as  the  patient  adhered  strictly  to  the 
prescribed  dietary  and  hygienic  regimen. 

Migraine  might  be  termed  a  cramp  in  the  head.  It  is 
somewhat  similar  to  angina  pectoris,  in  which  there  is 
often  a  cramp  of  the  left  arm,  with  coldness,  nuinbness, 
and  anaesthesia. 

I  have  a  patient  who  has  a  similar  cramp  in  the  third 
and  fourth  toes  of  the  right  foot ;  it  is  a  reflex  from  intes- 
tinal indigestion. 

Headache. 

This  is  the  most  common  of  all  nervous  symptoms  de- 
pendent upon  indigestion.  The  indigestion  is  usually  sec- 
ondary and  occurs  in  the  liver  without  any  apparent 
symptom  except  weakness  and  some  antemia.  Worry  and 
anxiety  are  factors  in  its  production,  by  primarily  inter- 
fering with  the  digestion. 

HypercBinic  Headache. — In  this  affection,  which  is  often 
toxic,  as  in  cases  of  malaria,  the  congestion  is  constant, 
and  may  last  for  weeks  if  no  remedial  measures  are  taken. 
The  greater  the  congestion  the  more  intense  the  pain.  Its 
seat  is  most  frequently  the  vertex  and  through  the  temples. 

In  many  cases  there  is  considerable  fever.  The  vaso- 
motor conditions  in  the  brain  are  undoubtedly  similar  to 
those  observed  in  the  face.  There  we  may  have  cerebral 
flushes,  morbid  flushing,  or  on  the  contrary  pallor,  due  to 
increase  or  diminution  of  the  blood  supply.  All  of  these 
phenomena  are  dependent  upon  vasomotor  changes. 

Treatment  of  Headache. — Quinine  may  be  given  as  a 
tonic,  and  with  iron  is  useful  in  relieving  this  condition. 


248  FUNCTIOXAL   :SrEEVOUS    DISORDERS. 

Tincture  of  nux  vomica,  in  ten-minim  doses,  is  also  a  very 
efficacious  remedy  in  removing  the  indigestion  and  conse- 
quent headache.  In  the  hypersemic  form  of  headache, 
digitaline  granules,  in  doses  of  one-sixtieth  of  a  grain, 
twice  daily,  are  often  of  use.  Bathing  the  head  with  alco- 
hol or  Easpail's  "Eau  Sedatif"  gives  at  times  marked 
relief.  Bromo-caffeine  is  a  preparation  that  relieves  tem- 
porarily many  cases  of  true  migraine.  It  often  seems  to 
act  like  magic,  but  the  effect  produced  is  not  lasting.  In 
bilious  headache,  dilute  nitro-muriatic  acid,  five  to  ten 
minims  in  water,  or  a  dose  of  the  phosphate  of  soda  will 
often  give  relief. 

Congestive  Headache. — Mrs.  S.,  a  widow,  age  42,  has 
for  a  week  past  had  constant  and  severe  headache,  worse 
at  night,  due  to  the  worry  and  care  of  a  large  boarding- 
house.  The  pain  affects  the  entire  head,  more  especially 
the  top  and  back.  The  urine  has  a  specific  gravity  of  1.014, 
is  of  light  color,  and  is  normal  in  quantity;  it  contains 
neither  albumin  nor  phosphates. 

The  patient  is  languid,  weak,  and  intensely  drowsy,  and 
usually  has  a  great  thirst,  due  to  chronic  gastric  catarrh. 

The  headaches  are  in  this  case  of  gastric  and  hepatic 
origin,  and  are  frequently  the  result  of  financial  worry. 
Under  a  lessening  of  the  mental  strain,  and  with  happier 
surroundings,  her  condition  has  markedly  improved. 

Migraine,  Congestive  Type,  Due  to  Chronic  Intersti- 
tial Nephritis. — Mrs.  M.,  age  55,  stout,  has  slight 
asthma.  Examination  of  the  urine  shows  albumin.  She 
is  careful  in  her  diet.  She  caught  a  severe  cold,  which 
manifested  itself  principally  by  an  attack  of  severe  mi- 
graine that  was  relieved  only  by  the  persistent  use  of 
large  hypodermic  injections  of  morphine.  It  lasted  about 
three  days.  She  had  a  similar  attack  before,  which  lasted 
so  long  that  the  diagnosis  of  the  attending  physician  was 
"inflammation  of  the  meninges  of  the  brain." 


HEMICRAXIA — MIGRAIXE.  249 

Migraine  and  Asthmatic  Bronchitis  Dependent  upon 
Indigestion. — Miss  S.  V.,  age  40,  has  asthmatic  bron- 
chitis of  long  standing.  Many  of  her  relations  have  died 
of  phthisis.  She  is  now  suffering  from  severe  migraine 
in  right  temple,  which  frequently  recurs.  That  it  is  of  a 
congestive  type  is  indicated  by  the  throbbing  and  enlarge- 
ment of  the  carotid  artery,  and  from  attacks  of  hemor- 
rhage on  the  same  side  of  the  nose.  For  a  year  past  she 
has  been  living  entirely  upon  vegetable  food,  of  which  she 
has  been  taking  excessive  quantities.  She  has  an  especial 
craving  for  fresh  bread.  She  dislikes  meat.  A  simple 
dietary  was  prescribed,  consisting  of  broiled  minced  beef, 
stale  bread,  hot  water,  etc.,  as  well  as  a  tonic  regimen, 
and  she  states  that  from  the  very  first  she  began  to  im- 
prove and  to  develop  an  appetite  for  meat.  She  now  likes 
it  very  much,  and  considers  it  a  great  luxury.  Breathing 
has  become  easier  and  the  asthma  has  entirely  disap- 
peared. Her  voice,  which  was  almost  entirely  lost,  has 
returned.  She  was  supposed  by  her  friends  to  be  a  case 
of  chronic  phthisis,  but  she  is  now,  after  three  days'  treat- 
ment, vastly  improved  in  health,  and  considers  herself 
quite  well. 

Hemicrania,  Dependent  upon  Maldigestion  and  upon 
Irritation  from  the  Left  Ovary. — Miss  J.  W.,  age  28,  is  a 
blonde,  unmarried,  well  educated  and  refined,  with  much 
strength  of  character ;  she  has  every  comfort.  When  I  first 
saw  her,  in  October,  1887,  she  was  suffering  from  hemi- 
crania. The  pain,  which  was  of  a  very  severe  character, 
was  localized  in  a  small  spot  on  the  right  side  of  the  head 
near  the  vertex.  The  attack  was  usually  so  severe  as  to 
cause  fainting;  she  complained  of  excruciating  pain  in  the 
left  ovary,  and  felt  as  if  she  might  lose  her  reason.  Octo- 
ber 26th,  1890,  while  suffering,  she  took  twenty-five  grains 
of  bromide  of  potassium,  which,  she  thought,  started  the 
pain  in  the  left  ovary,  and  this  was  followed  by  a  sense  of 
suffocation,  a  globus  hystericus,  and  a  hystero-epileptic 
attack.  When  I  saw  her  she  was  rigid  and  seemed  uncon- 
scious; she  was  surrounded  by  her  friends,  who  were  much 


250  FUJsrcTioisrAL  kervous  disorders. 

alarmed,  thinking  that  perhaps  she  had  poisoned  herself 
with  the  medicine.  She  seemed  unable  to  speak,  but 
after  taking  a  teaspoonful  or  two  of  brandy  and  water  she 
became  completely  conscious,  but  could  not  open  her  fin- 
gers, which  were  tightly  closed.  After  a  little  time  the 
contractions  relaxed  and  her  hands  opened.  She  com- 
plained of  creeping  sensations  all  over  her  body,  and  would 
continually  clasp  and  unclasp  her  fingers.  She  had  the 
usual  symptoms  of  migraine,  a  tendency  to  which  she  had 
inherited  from  her  mother.  Miss  W.  is  especially  liable 
to  have  these  attacks  in  the  early  spring,  and  when  for 
any  length  of  time  she  has  been  confined  to  the  house  with- 
out fresh  air.  They  are  also  brought  on  by  overwork. 
She  has  no  post-nasal  catarrh  nor  eye  trouble  as  causative 
factors. 

Bromide  of  caffeine  in  large  doses  gave  a  temporary 
relief.  A  short  sea  voyage  to  a  southern  port  was  recom- 
mended, and  was  productive  of  marked  benefit  by  greatly 
improving  her  general  health. 

Migrainous  Headache  as  a  Gastric  Neurosis. — ^Mrs. 
D.,  age  38,  has  had  two  children.  Whenever  there  is  an 
acid  condition  of  the  stomach  she  suffers  from  most  severe 
migrainous  headaches,  alternately  in  either  temple.  She 
has  also  severe  pains  over  the  greater  curvature  of  the 
stomach.  There  is  a  great  amount  of  flatulence  and  much 
intestinal  colic.  While  pregnant  she  is  unable  to  eat  meat 
or  other  solid  food  in  the  morning ;  she  takes  merely  coffee, 
and  during  the  day  consumes  a  good  deal  of  tea.  She 
takes  only  two  meals  dail}^,  one  at  11  a.m.,  and  the  other 
at  6  P.M.  She  has  a  craving  for  salt  meats,  for  vegetables, 
especialh^  potatoes,  and  for  fruit. 

Under  a  change  of  diet  there  was  a  marked  alleviation 
of  her  symptoms. 

In  many  of  these  cases  there  is  a  tendency  toward 
chronic  nephritis. 


CHAPTER  XXU. 

THERAPEUTICS. 

"In  other  cases  special  treatment  remains  ineffectual,  until  by 
generally  strengthening  treatment  the  vital  energies  have  increased 
and  the  process  of  recuperation,  latent  in  the  organism,  is  again 
aroused  to  life. " — Gustaf  Zander. 

In  the  treatment  of  these  neurasthenic  conditions  the 
most  important  factor  to  be  considered  is  vitality,  or  re- 
sistance to  disease;  it  should  be  carefully  studied  and 
every  effort  made  to  sustain  and  augment  it.  Often  by 
inspection  alone  the  skilful  physician  can  determine  quite 
accurately  the  vital  resistance  of  the  patient.  Some  indi- 
viduals are  of  "good  timber,"  while  others  can  only  be 
compared  to  punk.  The  first  seem  to  have  an  invincible 
power  of  resistance  to  the  effects  of  starvation,  accident,  or 
disease,  while  the  second  will  succumb  to  the  most  trifling 
ailment  or  casualty.  Many  thin  and  apparently  delicate 
persons  easily  resist  deleterious  influences,  and  if  affected 
quickly  recover;  while  some  stout,  and  to  all  appearances 
strong  individuals,  can,  under  the  same  conditions,  barely 
exist,  so  weak  is  their  vital  resistance.  Those  of  the  first 
class  are  endowed  at  birth  with  this  force  of  constitution, 
while  the  portion  of  the  others  is  inherited  weakness. 

Fear,  as  is  well  known,  is  a  great  factor  in  the  produc- 
tion of  disease ;  it  depresses  the  force  of  the  system,  thus 
weakening  the  vital  resistance.     It   causes   cold  sweats, 

diarrhoea,    excessive    urination,    disordered    perspiration, 

251 


252  FUNCTIOKAL   NERVOUS    DISORDERS. 

palpitation  of  the  heart,  and  jaundice.  By  this  depressing 
action  upon  the  vital  functions,  it  favors  the  onset  of  the 
disease  and  increases  its  malignity  when  present.  This 
is  commonly  seen  in  epidemics,  such  as  cholera,  typhus 
fever,  or  small-pox,  fear  causing  the  disease  in  many  who 
would  otherwise  escape. 

The  passions  of  the  mind  and  soul  have  as  important 
a  place  as  factors  in  the  production  of  disease  as  the  septic 
poisons  and  the  various  morbific  bacteria,  and  they  are  of 
special  importance  in  these  hysterical,  neurotic  affections. 

When  a  woman  is  in  the  full  vigor  of  health,  all  her 
functions  are  properly  regulated  and  are  always  the  same. 
The  heart  beat  is  slow,  full,  and  strong ;  the  respiration  is 
natural  and  unembarrassed;  the  nervous  system  is  per- 
fectly in  accord  with  the  rest  of  the  body.  When,  how- 
ever, weakness  supervenes,  all  sorts  of  aberrations  in  in- 
finite variety  occur.  As  much  of  the  disease  from  which 
nervous  women  suffer  is  of  bacteriological  origin,  the  pre- 
vention of  catarrhal  states  of  the  digestive,  respiratory,  or 
genital  tracts  by  internal  or  tissue  asepsis  (as  I  term  it)  is 
of  vast  importance. 

The  value  of  prophylaxis  should  be  more  appreciated 
than  it  is  in  our  daily  practical  work.  I  do  not  under- 
estimate the  importance  of  symptomatic  treatment  as  our 
routine  practice  demands  it,  but  we  should  not,  as  we 
are  prone  to  do,  confine  ourselves  to  dealing  exclusively 
with  symptoms  which  in  most  cases  arise  from  the  basic 
malady.  Our  conception  of  disease  must  be  broader.  By 
considering  the  basic  malady,  we  are  better  prepared  to 
meet  the  demands  of  modern  prophylaxis.  The  physician 
will  have  to  deal  with  the  pathological  tendency  to  non- 
bacteriological  affections,  such  as  retarded  growth,  anae- 
mia,  cardiac  weakness,  contracted  chest,  catarrhal   con- 


THEKAPEUTICS.  253 

ditions,  etc. ,  as  well  as  affections  of  microbic  origin,  with 
which  I  intend  to  deal  briefly.  In  these  days  hereditary 
predisposition  is  no  longer  regarded  from  a  fatalistic 
standpoint,  a  knowledge  of  hygiene  and  prophylaxis  giv- 
ing us  the  means  to  counteract  it ;  the  highest  art  of  the 
physician  lies  in  applying  this  knowledge  to  individual  • 
needs,  preventing  overexertion,  strengthening  weakened 
organs,  and  restoring  tone  to  the  system. 

Internal  sterilization  presents  many  difficulties  not  en- 
countered by  the  surgeon,  whose  treatment  can  be  local- 
ized. Internal  or  tissue  asepsis  is  a  complicated  matter, 
and  in  the  majority  of  cases  we  have  to  adopt  a  systema- 
tic constitutional  treatment.  Measures  which  vitalize  the 
organs,  promote  circulation,  metabolism,  and  tissue  change, 
and  so  contribute  to  the  building  up  of  the  whole  system, 
will  have  to  be  adopted,  and  will  consist  of  a  proper  die- 
tary, curative  exercise,  internal  and  external  hydrotherapy, 
electro-therapy,  change  of  climate,  or, appropriate  drugs, 
according  to  the  indications.  I  believe  that  medicines  are 
more  effective  in  a  patient  whose  vitality  has  been  in- 
creased than  in  one  whose  vitality  is  low.  The  internal  \ 
use  of  water  is  to  my  mind  a  valuable  means  of  restoring  \ 
tone.  (See  my  article  upon  the  subject  in  the  Medical 
Record  for  N"ovember,  1895.)  Dr.  Otto  Leichtenstern 
("Handbook  of  General  Therapeutics,"  Ziemssen,  Vol. 
IV.,  New  York,  1885)  says  that  the  effects  of  abundant 
water  drinking  are  in  close  connection  with  the  quantity 
and  temperature  of  the  water  taken  in.  The  effect  of  the 
drinking  of_cold  water  is  a  lowering  of  the  bodily  temper- 
ature, and  if  the  stomach  is  empty  it  leaves  it  very  quickh'. 
The  water  absorbed; through  the  mucous  membrane^nhe 
stomach  and  intestines  is  in  large  part  taken  up  by  the 
veins,  notably  the  vena  portoe,  as  well  as  by  the  lymphat- 


254  FUJiTCTIOIsrAL    N"ERYOrS    DISORDEES. 

ics.  There  is  no  diminution  of  the  specific  gravity  of  the 
blood,  as  has  been  shown  by  the  experiments  of  Magendie, 
Nasse,  Denis  and  Leichtenstern,  nor  is  any  increase  of 
water  observed  after  copious  water  drinking.  This  is  due 
to  the  fact  that  as  soon  as  the  water  is  absorbed  from  the 
stomach  and  intestines  it  begins  to  be  excreted  in  the  urine. 
Thus  a  large  amount  of  water  can  pass  through  the  body 
in  a  short  time  without  causing  any  demonstrable  increase 
of  the  amount  of  water  in  the  blood.  The  water  distrib- 
utes itself  not  only  to  the  blood  current  but  also  to  the 
fluids  of  the  tissues  in  all  parts  of  the  body.  Leichten- 
stern says  that  we  have  in  copious  water  drinking,  a 
means  of  subjecting  the  whole  system  to  a  powerful  wash- 
ing out,  and  a  consequence  of  this  is  the  temporary  in- 
creased excretion  of  certain  products  of  the  tissue  changes. 
He  says  that  although,  so  far  as  he  knows,  "  no  thorough 
experiments,  not  open  to  exception,  have  as  yet  been  made 
on  the  action  of  copious  water  drinking  in  conversion 
of  tissue,  yet  experiments  up  to  the  present  time  warrant 
the  following  conclusion:  .  .  .  The  greater  myiount  of 
diuresis  after  drinking  large  quantities  of  ivater  pro- 
duces a  quantitative  increase  of  the  excretion  of  urea, 
of  chloride  of  sodium,  of  phosphoric  and  of  sidphuric 
acids.''^  It  has  also  been  shown  that  the  amount  of  uric 
acid  is  diminished  by  copious  water  drinking.  Investiga- 
tors have  found  an  increase  in  urea,  and  the  increase  of 
salts  in  the  urine  has  been  proved  by  the  experiments  of 
half  a  dozen  different  observers.  Without  doubt  the  in- 
creased quantity  of  water  which  permeates  the  tissues 
favors  the  decomposition  of  the  waste  albumin,  and  thus 
augments  the  excretion  of  urea ;  there  may  be  also  a  more 
rapid  removal  of  the  urea  already  formed,  but  the  major- 
ity of  authors  believes  the  increased  conversion  of  the  albu- 


THERAPEUTICS.  255 

minates  to  be  the  main  factor.  Xew  and  thorough  experi- 
ments upon  this  subject  may  be  desirable,  but  for  my  part, 
I  do  not  consider  them  to  be  necessary.  Leichtenstern  still 
further  says :  "  Unquestionably,  numberless  cures  owe  more 
of  their  efficacy,  in  diseases,  to  the  diuretic  and  washing- 
out  effect  of  the  water  drunk  in  increased  quantity  than 
to  the  salts  and  gases  dissolved  in  it.  We  make  the  most 
extensive  use  of  this  washing-out  power  of  water  in  thera- 
peutics. Copious  water  drinking,  may,  under  proper  cir- 
cumstances, be  used  efficaciously  in  many  cases :  when  it 
is  the  object  to  bring  exudations  to  absorption,  to  wash 
out  accumulated  particles  of  bile  from  the  blood  and  from 
the  tissues,  to  increase  the  secretion  of  bile  and  the  press- 
ure of  the  secreted  bile;  when  it  is  the  object  to  remove 
certain  poisons  which  have  got  into  the  system,  or  to  wash 
out  blocked  up  urinary  tubuli.  In  all  these  cases  where 
large  quantities  of  water  are  employed,  simple  water  (I 
include  here  distilled  water  with  any  addition  to  make  it 
palatable)  is  to  be  preferred  to  mineral  waters  or  to  solu- 
tions of  salts.  And  as  water  in  large  quantities  is  better 
borne  by  the  stomach  taken  \varm  than  cold,  the  use  of 
the  former  is  preferable,  and  besides  that  it  is  more  rapidly 
diffused."  "  It  is  known  that  other  excretions  besides  that 
of  urine  are  influenced  by  copious  water  drinking.  Leh- 
man observed  in  the  horse  an  increased  secretion  of  the 
parotid,  the  specific  gravity  of  which  at  the  same  time 
became  lighter;  and  Weinman  witnessed  a  considerable 
increase  in  the  pancreatic  secretion  of  the  animal  experi- 
mented upon,  after  a  large  suppty  of  water.  Bidder, 
Schmidt,  Nasse,  Arnold,  found  the  secretion  of  bile  in- 
creased after  copious  draughts  of  water,  the  specific  grav- 
ity of  bile  diminished,  and  the  amount  of  solid  matter  / 
excreted  through  it  increased. 


256  FUNCTIONAL   NERVOUS    DISOEDERS. 

"  Copious  Water  Drinking  Increases  the  Seiisihle  and 
Insensible  Transpiration  of  the  Skin,  in  Health  and  in 
Many  Diseases.  This  has  been  proved  by  innumerable 
experiments  which  have  been  made  by  Ferber,  Hosier, 
Weyrich,  and  repeated  in  Niemeyer's  clinic." 

Where  a  small  quantity  of  chloride  of  sodium  is  con- 
tained in  the  water,  as  at  salt  springs,  the  secretion  of  the 
gastric  juice,  which  is  strongly  antiseptic,  is  stimulated 
and  increased;  the  formation  of  peptone  is  also  favored, 
and  reflexly  the  salt  excites  the  peristaltic  action  of  the 
stomach  and  intestines,  and  thus  furthers  the  removal  of 
any  stagnating  contents  which  would  otherwise  remain  for 
a  longer  time  in  the  digestive  canal.  Salt  has  also  a  slight 
[diuretic  action.  With  a  slight  increase  of  the  supply  of 
'  chloride  of  sodium,  there  is  an  increased  excretion  of  nitro- 
gen through  the  urine.  Voit  says  that  this  action  of  chlo- 
ride of  sodium  is  caused  by  its  increasing  the  celerity  of 
diffusion  of  the  current  of  fluids  through  the  tissues,  so 
that  larger  amounts  of  the  circulating  albumin  are  exposed 
to  the  breaking-up  powers  of  the  cells.  The  practitioners 
at  Bath,  England,  according  to  Leichtenstern  "make  the 
fullest  use  of  this  important  physiological  fact,  and  of  its 
explanation,  in  expounding  the  curative  effects  of  the  salt 
waters,  as  well  as  in  laying  down  indications  for  their  use. 
The  salt  waters,  they  say,  'powerfully  excite  the  conver- 
sion of  tissue' ;  hence  their  favorable  operation  in  'general 
plethora,'  'in  over-nutrition,'  in  obesity,  etc. 

"  While  the  salt  waters  promote  the  circulation  of  the 
fluids  also  through  pathological  products,  plastic  and 
other  formations,  they  loosen  their  structure,  carry  away 
their  albuminates,  and  favor  their  combustion ;  along  with 
this,  fat  is  formed  in  the  pathological  products,  which  now 
can  easily  be  absorbed.     On  this  is  based  the  theory  of  the 


THERAPEUTICS.  257 

curative  effects  of  salt  water  in  scrofulosis,  with  its  many 
exudations  and  hyperplasias  of  the  glands;  on  this  rests 
the  theoretical  indication  for  the  use  of  these  waters  in  the 
most  varied  exudations  of  different  organs,  especially  in 
chronic  infarction  of  the  uterus,  in  chronic  exudations  of  i 
the  pelvis,  in  peri-  and  para-metritis,  etc.   ...  ' 

"  Voit  announces  as  a  further  property  of  salt,  that  it 
influences  the  solubility  and  the  diffusibility  of  albuminous 
matters.  On  these  no  doubt  correct  conclusions  of  the 
physiologist,  balneotherapists  ground  the  important  thera- 
peutic effects  of  the  salt  waters.  To  use  their  modes  of 
expression,  salt  waters  'stimulate  and  heighten  the  plastic 
activity  of  the  organism,  facilitate  the  formation  of  cells, 
increase  the  number  of  blood  corpuscles,  lower  the  amount 
of  water  and  of  albumin  of  the  blood,'  and  as  these  waters, 
as  we  said  above,  at  the  same  time  increase  the  combustion 
of  albuminates,  they  should  possess  the  remarkable  property 
of  regenerating  the  whole  organism,  of  pv^rifying  it  of  its 
injurious  dross,  and  of  renewing  its  youth.  The  problem 
of  Medea  would  thus  be  solved  in  f-:o  simplest  way,  by 
salt  waters.  Diruf  pointed  out  as  a  fact  'which  could  not 
be  sufficiently  proclaimed,'  in  a  therapeutical  point  of 
view,  that  a  'moderately  increased  supply  of  chloride  of 
sodium  is  able,  under  certain  conditions,  to  induce,  along 
with  the  accelerated  conversion  of  nitrogenous  tissues,  an 
excess  of  formative  over  removing  action  in  the  sj'stem, 
and  in  other  cases  to  reverse  the  process.'  Certainly  a 
very  convenient  if  not  a  very  clear  theory  for  explaining 
the  efficacy  of  salt  waters  in  the  most  different  forms  of 
disease,  a  fact  which  cannot  be  empirically  gainsaid. 

"Chloride  of  sodium  is  said  to  increase  Hhe  secretion  of 

various  mucous  surfaces,'  and  especially  that  of  tlie  organs 

of  respiration.     It  is  said  to  act  as  an  'anticatarrhal,'  as  a 
17 


258  FUNCTIONAL    NEKVOUS    DISOEDERS. 

'solvent  of  mucus'  to  'regulate  the  nutritive  condition  of 
the  affected  mucous  membrane,'  etc.  Hence  the  recom- 
mendation of  these  waters  in  catarrh  of  the  respiratory- 
organs;  the  lion's  share  of  the  empirically  proved  efficacy 
of  these  v^aters,  in  such  affections,  is  no  doubt  to  be  as- 
cribed to  their  w^armth." 

Anything  vrhich  destroys  the  micro-organisms  that  are 
detrimental  to  the  bodily  health  is  an  antiseptic ;  therefore 
dietetic  treatment  in  its  broadest  sense,  which  includes 
curative  exercise,  hydrotherapy,  etc.,  as  well  as  the  scien- 
tific selection  and  preparation  of  food,  is  antiseptic,  as  it 
enhances  the  vitality  and  bodily  resistance  to  disease  bac- 
teria, by  increasing  the  germicidal  power  of  the  blood. 

As  many  nervous  women  are  tuberculous,  or  are  from 
their  anaemic  condition  in  danger  of  contracting  tuber- 
culosis, a  few  words  upon  its  prophylaxis  will  not  be  out 
of  place. 

Up  to  about  twelve  years  ago  the  treatment  of  tubercu- 
losis was  entirely  empirical.  In  1882  Robert  Koch,  of 
Berlin,  for  the  first  time  proved  beyond  a  doubt  that  this 
disease  was  caused  by  bacilli  which,  on  account  of  their 
peculiar  behavior  toward  strong  acid,  could  be  positively 
diagnosed  in  every  case  of  tuberculosis.  All  subsequent 
experiments  have  shown  that  Koch's  statements  were  per- 
fectly correct,  and  to-day  we  can  say  that  there  is  no 
tuberculosis  without  the  presence  of  these  characteristic 
tubercle  bacilli.  It  is  true  that  at  the  commencement  of 
the  affection  it  is  not  always  easy  to  find  the  bacilli,  but 
careful  examination  of  the  sputa  at  different  times  will 
invariably  show  their  presence  in  a  greater  or  less  degree. 

Tuberculosis  maj^  start  very  slowly  and  graduall}^;  so 
much  so  that,  physically,  no  characteristic  symptoms  of 
the  disease  may  be  found,  but  examination  of  the  sputa 


THERAPEUTICS,  259 

will  already,  at  this  early  period,  demonstrate  the  presence 
of  the  bacilli.  In  every  case  of  cough  which  has  lasted 
for  some  time  the  physician  should  invariably  make  it  the 
rule  to  examine  the  sputum,  whether  he  suspects  tuber- 
culosis or  not.  If  this  is  done,  and  only  then,  can  we  ex- 
pect better  results  from  our  treatment  than  we  have 
heretofore  achieved. 

In  a  large  number  of  cases  bacilli  may  be  found  in  the 
{^uta  long  before  there  are  any  well-marked  physical  signs, 
so  that  their  detection  will  afford  the  first  clew  to  the  pa- 
tient's maladj'.  Even  at  the  present  day  some  physicians 
claim  that  there  are  cases  of  phthisis  without  the  presence 
of  tubercle  baciUi.  The  trouble  with  them  will,  however, 
simply  lie  in  the  meaning  of  the  word  "phthisis,"  as  some 
will  call  a  chronic  catarrhal  pneumonia  fibroid  phthisis. 
That  this  is  not  tuberculosis  need  hardly  be  mentioned. 

Another  mistake  which  is  often  made  is  to  call  tubercle 
bacilli  the  sole  cause  of  tuberculous  infection,  since  tubercu- 
losis will  never  affect  people  with  good  constitutions,  but 
only  those  with  poor,  broken-down  constitutions.  People 
with  good  constitutions  may  continually  inhale  the  bacilli 
without  an}^  bad  effects  whatever.  The  human  body 
may  be  in  a  condition  that  is  termed  health,  and  still 
pathogenic  bacteria  may  be  present;  these  are  kept  in 
abeyance  by  the  defensive  action  of  the  blood -serum  and 
leucocytes.  It  is  this  repressive  power  of  the  blood  that 
keeps  them  from  propagating  and  doing  injury  to  the 
economy. 

Bacteria  often  seem  to  be  destroyed  by  phagocytosis. 
There  is  an  antibacterial  property  in  the  tissues,  fluids, 
and  secretions  of  the  body,  and  these  are  natural  defences 
against  the  growth  of  micro-organisms.  The  contact  of 
germs  does  not  lead  to  infection   unless  the  material  is 


260  FUIs"CTIOXAL   ]Si"ERVOUS    DISORDERS. 

present  to  favor  their  development.  One  of  these  causes  is 
a  poor  or  broken-down  constitution.  When  this  is  present 
any  existing  bacteria  will  multiply  and  thrive.  Another 
cause  is  the  presence  of  the  products  of  fermentation,  in- 
flammatory exudates,  and  diminished  blood-supply.  If 
the  constitution  is  improved,  and  the  pabulum  upon  which 
the  bacteria  thrive  removed  or  its  formation  stopped,  their 
development  is  hindered  or  entirely  checked,  and  thus  the 
severer  forms  of  inflammation  are  obviated.  A  plant  can- 
not grow  upon  a  rock  or  thrive  upon  barren  soil,  and  so  it 
is  with  all  forms  of  life,  even  the  minute  organisms.  The 
substances  upon  the  surfaces  of  wounds  which  cause  the 
development  of  micro-organisms  and  thus  produce  infec- 
tion, are  readily  removed  by  the  most  important  and  chief 
means  for  all  sterilization;  that  is,  the  mechanical  purifi- 
cation b}^  washing  and  cleansing  with  water.  Why 
should  not  the  substances  in  the  interior  of  the  organism, 
which  are  the  pabulum  for  bacterial  development,  also  be 
removed,  at  least  to  a  great  extent,  through  the  channels 
of  the  body  which  terminate  directly  in  the  emunctory 
organs?  It  is  quite  possible  that  the  sewerage  system  of 
the  tissues,  when  properly  stimulated  in  the  work  of  elimi- 
nation, will  carry  along  in  its  circulation  much  of  the 
material  which  causes  infection,  and  thus  produce  what 
might  be  termed  an  internal  sterilization  or  asepsis.  Many 
seem  to  think  that,  after  a  germ  has  once  entered  the 
body,  it  cannot  be  removed  until  it  is  thoroughly  digested; 
but  why  should  not  cleanliness,  applied  to  the  internal 
organs  whenever  possible,  aid  in  the  elimination  of  the 
micro-organisms?  If  we  cleanse  the  oral  cavit}^  daily,  we 
may  just  as  well  go  farther  and  cleanse  the  stomach,  intes- 
tines, and  the  tissues.  Tubercle  and  other  bacilli  usually 
enter  the  organism  by  the  canals  and  ducts  which  commu- 


THERAPEUTICS.  261 

nicate  with  the  outside  of  the  bod}-.  The  alimentaiy  canal 
in  many  cases  is  the  primary  means  of  entrance.  The  infec- 
tion then  extends  by  following  various  routes.  The  bacilli 
are  carried  along  the  lymphatic  channels  into  the  tissues 
or  lymphatic  glands.  These  glands  appear  to  have  the 
power  of  arresting  the  infection,  for  a  time  at  least,  before 
it  finally  passes  into  the  blood,  and  this  would  seem  to  be 
the  critical  period  in  the  treatment.  Pure  or  sterilized 
granite  or  trap-rock  waters  taken  hot  in  sufficient  quanti- 
ties and  at  proper  times,  combined  with  systematic  mus- 
cular exercise,  hot  baths,  and  massage,  will  certainl}^  help 
to  cleanse  out  the  tissues  of  the  bod}'. 

We  msiy  furthermore  take  advantage  of  the  bactericidal 
properties  of  the  blood  serum.  This  protective  property  of 
nature  is  best  enhanced  by  enriching  the  blood  by  the 
various  means  within  our  power,  one  of  the  most  important 
of  which  is  scientific  dieting.  The  ordinary  diet  of  indi- 
viduals is  often  extreme!}'  bad,  the  place  of  wholesome  food 
being  taken  by  sweets  and  stimulants,  such  as  sugar,  pas- 
try, tea,  coffee,  and  alcoholic  drinks,  so  that  not  infre- 
quently patients  will  grow  weak  and  the  constitution  will 
suffer  simply  on  account  of  the  deprivation  of  proper 
nourishment. 

The  plan  of  treatment,  which  I  have  already  described 
in  the  New  York  Medical  Journal  for  October,  1894, 
consists  in  giving  at  rather  frequent  intervals  a  consider- 
able quantity  of  carefully  roasted  or  broiled  beef  or  mut- 
ton, raw  eggs,  stale  bread,  butter,  sterilized  milk,  and 
vegetables.  After  a  few  days  of  treatment  the  meat 
should  not  be  less  in  amount  than  a  pound  a  day,  and  the 
quantity  of  bread  and  A^egetables  should  be,  if  possible, 
somewhat  larger.  When  there  is  a  disgust  for  the  meat 
diet  the  stomach  needs  special  treatment,  for  a  short  time 


263  FUJfCTIONAL    KERVOUS    DISORDERS. 

only,  by  the  addition  of  a  digestant,  such  as  dilute  hydro- 
chloric acid  and  hot  water  to  remove  irritations. 

Tuberculosis  is  the  great  destroj'er,  as  it  is  the  most 
frequent  of  all  fatal  diseases;  and  malnutrition  and  de- 
fective elimination,  which  will  sooner  or  later  break  down 
the  constitution,  are  at  its  foundation.  It  is  estimated 
that  in  the  United  States  nearly  five  hundred  individuals 
die  of  this  disease  every  twenty-four  hours.  Its  extreme 
prevalence  and  destructiveness  have  urged  physicians  in 
all  countries  to  make  strenuous  efforts  for  its  prevention 
and  extermination. 

It  has  been  mentioned  in  this  work  a  number  of  times 
that  constitution  is  one  of  the  most  important  points  in 
the  development  of  tuberculosis.  It  may  be  well  to  shovv^ 
how  the  constitution  of  the  patient  can  easil}'  be  deter- 
mined under  the  microscope.  Not  only  may  this  be  done 
by  the  colorless  blood  corpuscles,  but  also  by  the  inflam- 
matory pus  corpuscles  which  we  will  invariably  find  pres- 
ent in  every  sputum  in  which  there  is  an  inflammation  of 
any  kind  whatever. 

These  views  were  first  announced  by  Carl  Heitzmann  in 
1879,  and  have  since  been  corroborated  by  a  number  of 
independent  observers  both  here  and  abroad.  They  are 
the  following:  The  amount  of  living  matter  within  a 
limited  bulk  of  a  corpuscle  varies  greatly  in  different  in- 
dividuals. It  is  obvious  that  what  is  called  a  healthy  or 
vigorous  constitution  is  based  upon  a  large  amount  of  liv- 
ing matter  in  the  body,  the  new  growth  of  which  in 
morbid  processes  is  very  lively;  while  a  phthisical  or  so- 
called  scrofulous  diathesis  must  be  caused  by  a  relatively 
small  amount  of  living  matter,  the  new  growth  of  which 
is  scanty  in  morbid  processes.  In  other  words,  a  corpuscle 
will  exhibit  coarse  granulation,  or  it  will  be  almost  homo- 


THEKAPEUTICS.  263 

geneous-looking,  under  the  microscope,  owing  to  the  large 
amount  of  living  matter  in  strong  individuals  of  good 
constitution;  while  a  corpuscle  taken  from  a  person  with 
a  weak  or  tuberculous  constitution  will  be  pale  and  finely 
granular,  as  but  little  living  matter  is  present  in  it.  In  a 
given  case,  therefore,  the  more  numerous  the  coarsely 
granular  pus  corpuscles  or  colorless  blood  corpuscles  pres- 
ent, the  better  the  constitution;  and,  on  the  other  hand, 
the  more  abundant  the  finely  granular  ones,  the  worse  the 
constitution;  and  when  the  corpuscles  become  broken  up 
and  disintegrated  we  can  say  that  death  is  not  far  distant. 
As  long,  then,  as  we  find  the  coarsely  granular,  homogene- 
ous corpuscles  predominating,  so  long  there  will  be  no 
danger  of  the  individual  contracting  tuberculosis;  and 
when  upon  examination  we  find  that  the  corpuscles  do  not 
contain  a  sufficient  amount  of  living  matter,  that  is,  they 
have  become  more  or  less  finely  granular,  we  should  at 
once  resort  to  all  possible  means  to  increase  the  living 
matter,  as  otherwise  tuberculosis  may  set  in  at  any  time. 

Klebs,  in  the  Journal  of  the  American  Medical  Asso- 
ciation for  October  12th,  1895,  says,  in  speaking  of  anti- 
phthisin  in  tuberculous  affections  of  children : 

"  It  would  certainly  be  unreasonable  to  demand  that  this 
remedy,  which  has  a  specific  germicidal  effect  upon  the 
tubercle  bacillus  only,  shall  also  remove  and  cause  the  cure 
of  pathologic  changes  which  result  remotely  from  the 
primary  cause,  and,  more  unreasonable  still,  that  the  rem- 
edy shall  also  favorably  influence  and  cure  complications 
which,  like  infection  with  other  pathogenic  germs,  have 
no  relation  to  tuberculosis  at  all,  more  than  that  they  may 
be  associated  in  the  same  patient. 

"  In  all  such  cases  it  is  necessary  to  remove  the  compli- 
cations by  other  treatment,  either  before  or  in  "conjunction 


264  FUXCTIOXAL    XER VOL'S    DISORDERS. 

with  the  appHcation  of  the  specific  remedy;  but  the  final 
results  are  determined  by  the  importance  and  curability 
of  such  attending  pathologic  processes. 

"  We  see,  thus,  that  the  use  of  a  specific  germicidal  rem- 
edy can  only  be  fully  effective  when  the  disease  is  stiU 
uncomplicated  by  secondary  degenerations,  and  is  free 
from  complications  which,  unfortunately",  are  present  in 
most  cases  of  tuberculous  disease  as  they  come  under  our 
notice;  there  are,  however,  not  a  few  cases  of  purely 
tuberculous  affections  in  an  early  stage  in  which  the  results 
of  specific  medication  are  highly  satisfactory.  .  .  .  For 
these,  as  in  all  other  therapeutic  efforts,  the  only  unavoid- 
able condition  is  that  the  organism  itself  shall  still  have 
the  power  to  use  and  appropriate  the  introduced  curative 
substance;  for  under  no  circumstances  can  we  otherwise 
conceive  the  cure  of  disease  than  that  the  living  organism 
must,  itself,  take  an  active  part  in  its  removal." 

In  closing  his  paper  he  says :  "  Finally,  I  wish  to  point 
out  that,  in  all  tuberculous  affections,  the  same  as  in  many 
other  severe  and  serious  diseases,  their  treatment  in  hos- 
pitals or  special  institutions  offers  great  advantages  over 
that  of  private  practice." 

The  means  of  imjDroving  the  general  constitution  have 
already  been  partly  stated  above,  but  I  wish  to  dwell  espe- 
cially upon  the  good  results  obtained  from  regular  syste- 
matic physical  exercise.  The  medical  profession  has 
always  deemed  physical  education  a  hygienic  measure  of 
the  greatest  importance. 

The  well-known  Dr.  Gustaf  Zander  says ;  "  Experience 
having  shown  that  regular  muscular  exercises,  gradually 
made  more  strenuous,  not  only  develop  and  strengthen  the 
muscles,  but  promote  the  removal  of  pathological  changes 
in  the  tissues,  give  tone  to  the  nervous  system,  and  vitalize 


THERAPEUTICS.  265 

the  circulation  of  the  blood  and  lymph  and  the  activity 
of  many  organs,  it  is  natural  that  such  exercises  should  be 
included  among  therapeutic  agents.  For  this  purpose 
there  was,  however,  requisite  the  power  to  execute  these 
exercises  according  to  physiological  laws,  and  to  modify 
their  action,  like  that  of  anj^  other  therapeutic  agent,  ac- 
cording to  the  needs  of  each  individual  case."  Therefore 
those  persons  who  take  up  physical  culture  without  a  com- 
petent medical  instructor  maj^  do  themselves  serious  in- 
jury, or  at  least  obtain  no  special  benefit  from  it,  by 
attempting  methods  unsuited  to  their  phj'sical  condition, 
or  neglecting  to  carry  out  a  practical  system  in  a  proper 
manner.  Phj'sical  exercise  at  home  soon  becomes  a  mat- 
ter of  drudgery  to  the  weak  and  poorly  developed,  who 
especially  require  it.  As  the  interest  is  lost,  it  is  neglected 
or  carried  out  in  a  desultory  manner,  and  thus  the  beneficial 
results  are  not  obtained.  Under  a  competent  medical  in- 
structor there  is,  along  with  sustained  interest,  a  rapid 
and  harmonious  development  of  those  portions  of  the  body 
which  most  need  it.  Hysterical  women  and  neurasthenic 
patients  of  both  sexes  especially,  and  also  children,  should 
not  be  allowed  to  take  this  exercise  at  home,  as  thej'  per- 
form it  without  system,  overdoing  it  one  day  and  entirely 
neglecting  it  the  next.  Very  judicious  passive  exercise 
should  begin  the  treatment,  which  should  be  gradually  in- 
creased ;  at  the  same  time  the}^  are  under  control,  which 
strengthens  their  will  power,  and  the}'  have  to  obey  instead 
of  ordering  others  about. 

The  indications  and  contraindications  for  muscular  exer- 
cise should  be  carefully  determined.  Exercise  does  not  do 
everything;  sometimes  rest  and  drugs  are  needed.  Ther- 
apeutics always  belong  to  the  physician,  and  not  to  the 
layman.     The  massage  following  the  bath  is  something 


266  PUXCTIOXAL   is^EEYOUS   DISOEDERS. 

difficult,  and  with  many  impossible,  to  obtain  at  home, 
and  it  should  not  be  in  the  hands  of  laymen.  In  ansemic, 
nervous  women  with  bad  carriage,  to  overcome  the  de- 
formity of  round  shoulders,  the  muscles  of  the  back  and 
abdomen  must  be  systematically  exercised  and  strength- 
ened. The  flattening  of  the  chest,  which  is  the  result  of 
the  shoulders  falling  forward,  tends  to  the  production  of 
lung  disease,  by  interfering  with  their  complete  expansion. 
To  overcome  this  deformity,  the  patient  should  stand  with 
head  erect,  with  the  abdomen  drawn  back  and  chest  pro- 
jecting, and  then  forcibly  draw  the  shoulders  back  as  far 
as  possible,  as  if  to  make  the  shoulder-blades  meet.  This 
should  be  performed  from  ten  to  fift}''  times  daily;  in  fact, 
at  frequent  intervals  during  the  day,  whether  exercising- 
or  not.     All  shoulder  braces  are  useless  for  this  purpose. 

For  broadening  the  chest,  assume  the  erect  posture. 
The  movement  should  be  as  follows:  Starting  with  the 
hands  in  front  of  the  hips,  force  them  by  a  lateral  and 
backward  movement  as  high  above  and  behind  the  head 
as  possible.  A  modification  of  this  movement,  which  is 
easier  and  more  graceful,  consists  in  starting  with  the 
arms  extended  behind  the  back,  and  letting  them  go  up 
alternately  as  far  as  possible,  while  keeping  the  elbows 
perfect^  rigid.  All  these  exercises  are  best  performed 
with  light  dumbbells,  from  two  to  five  pounds  in  weight. 
This  last  movement  is  of  especial  advantage  in  drawing 
upward  and  outward  the  sides  of  the  chest,  thus  increas- 
ing its  capacity. 

Another  beneficial  exercise  for  deepening  the  chest  and 
straightening  the  shoulders,  is  to  stand  with  arms  project- 
ing straight  forward,  elbows  perfectly  stiff.  Let  the  arms 
go  straight  backward  as  far  as  they  will,  on  a  level  with 
the  shoulders.     Meanwhile,    the   erect    posture   must    be 


THERAPEUTICS.  267 

maintained — head  erect,  chest  projecting,  and  chin  drawn 
in.  This  is  a  splendid  exercise  for  increasing  the  lung 
capacity'.  These  movements  should  be  repeated  until  the 
particular  muscles  involved  become  fatigued,  when  the 
instructor  will  change  them  and  bring  into  use  another  set 
of  muscles,  and  so  on.  The  respiration  should  be  full  and 
free,  and  the  air  perfectly  pure.  A  system  of  this  kind, 
carried  out  in  a  scientific  manner,  strengthens  not  only  the 
muscles,  but  all  the  vital  functions,  and  is  adapted  not 
only  to  adults,  but  to  children  as  well.  Respiration  and 
digestion  are  improved  with  the  increase  of  vitality,  and . 
the  elimination  of  the  waste  of  the  body  is  greatly  en- 
hanced. By  specific  exercises  the  chest  cavity  is  broad- 
ened and  deepened,  and  the  chest  expansion  and  manner 
of  breathing  greatly  improved  and  permanently  benefited. 
Not  only  the  lungs,  but  the  brain  and  nervous  system  are 
powerfully  influenced  by  systematic  bodily  exercise.  The 
brain  will  accomplish  only  imperfect  results  if  the  body  is 
not  in  a  state  of  health. 

Everywhere  we  see  the  lack  of  physical  exercise ;  men, 
women,  and  children  with  narrow  chests,  pale,  emaciated 
faces,  and  a  general  look  of  exhaustion  are  met  daily.  If 
extreme  leanness  is  not  present,  obesity  produces  ugliness 
of  the  human  form.  A  comely,  erect,  well-formed  body 
is  much  less  common.  Judicious  sj'stematic  muscular  ex- 
ercise and  a  proper  dietary  give  vigor,  activity,  and  cour- 
age, both  mental  and  physical. 

The  supply  of  oxygen  is  greatly  increased  by  deep,  full 
inhalations  in  the  open  air,  thus  increasing  the  lung  capac- 
ity, purifying  the  blood,  and  strengthening  the  nervous 
system.  The  temperature  of  the  body  is  equalized  as  a 
result  of  the  muscular  exercise  and  the  eliminative  sys- 
tem stimulated  to  increased  activity,  while  digestion  and 


268  FUIS^CTIONAL   NERVOUS   DISOEDEES. 

assimilation  are  brought  to  their  highest  point  of  effi- 
cienc3\ 

I  desire  to  refer  at  this  point  to  Dr.  Wischnewetzky, 
who  first  established  a  complete  mechanico-therapeutic 
Zander  institute  in  this  country,  and  directed  it  for  five 
years,  but  at  present  has  no  connection  with  the  institu- 
tion. He  says  in  "  Contributions  to  Mechanico-Therapeu- 
tics  and  Orthoposdics,"  Vol.  I.,  No.  2:  "By  affording  a 
basis  for  the  scientific  medical  application  and  discussion 
of  mechanico-therapeutics,  Dr.  Zander  has  placed  the  sub- 
ject above  the  level  of  a  peculiarly  Swedish  method,  and 
has  enriched  the  science  of  medicine.  Hence,  although 
Dr.  Zander  is  a  Swedish  physician,  his  method  can  no 
more  be  called  Swedish- than  pathological  anatomy,  which 
has  been  so  effectively  promoted  in  Germany,  is  German, 
or  antiseptic  surgery  English,  because  Joseph  Lister  was 
born  in  England.  .  .  . 

"  The  phj^sician  has  here  forced  the  mechanical  progress 
of  our  age  into  the  service  of  medicine  for  the  solution  of 
problems  of  an  anatomical  nature.  He  enables  us  to  exer- 
cise any  given  group  of  muscles  strictlj^  in  accordance  with 
the  laws  of  physiology  ;  to  exclude  any  other  groujo  at  will ; 
to  determine  which  groups  are  called  into  action,  and  to 
what  extent  in  every  movement  made. 

^'By  subjecting  to  localization,  measurement,  and  con- 
trol a  therapeutic  agent  which,  for  want  of  these  qualifica- 
tions, was  not  susceptible  of  rigid  scrutiny.  Dr.  Zander 
has  created  the  basis  for  the  use  of  mechanical  treatment 
as  an  agent  capable  of  fulfilling  all  the  conditions  imposed 
by  the  most  exigent  scientific  criticism. 

"  The  importance  of  systematicalh'  organized  muscular 
exercise  is  no  longer  a  subject  of  debate.  The  question 
always  open  for  the  conscientious  physician  is :     '  How 


THEBAPEUTICS.  209 

shall  such  treatment  be  admiuistered  without  risk  of  harm 
and  with  all  the  benefit  which  is  in  many  cases  obtainable 
from  it?'" 

Alimentation  and  Hygiene. 

Correct  alimentation  in  nervous  derangements  is  most 
important.  To  secm-e  healthy,  rich  blood,  proper  food 
and  good  digestion  are  necessary.  In  many  patients  suf- 
fering from  functional  nervous  disorders  there  may  be  a 
depraved  appetite  present,  and  in  other  cases  the  appetite 
may  be  entirely  absent,  so  that  the  amount  of  nourishment 
obtained  by  these  patients,  if  they  are  left  to  follow  their  own 
inclinations,  will  be  very  small,  although  they  may  partake 
of  large  quantities  of  indigestible  and  unwholesome  food. 

Indigestion  is  a  common  causative  factor  in  the  produc- 
tion of  functional  nervous  disorders.  Those  who  are  en- 
gaged in  intellectual  work,  such  as  journalists,  lawyers, 
physicians,  and  other  professional  men  who  lead  seden- 
tary lives,  are  most  likely  to  have  functional  disorders  as 
a  result  of  indigestion.  But  indigestion  is  most  common 
in  nervous  women.  Conditions  of  high  pressiire  and  men- 
tal strain,  such  as  striving  for  financial  and  social  success, 
cause  the  overtaxed  and  exhausted  stomach  to  rebel. 
Worry  and  anxiety  cause  a  condition  of  mental  depres- 
sion :  the  patient  is  distrustful  of  herself  and  of  the  future, 
and,  neglecting  exercise,  mopes  at  home  without  enlivening 
distraction,  the  result  being  an  impaired  digestion  and  a 
lowered  state  of  the  nervous  system.  These  women,  as  a 
result  of  their  imperfect  digestion,  are  almost  always  irri- 
table and  find  difificulty  in  exercising  sufficient  seK-controI 
to  make  life  pleasant  to  themselves  and  their  friends.  In 
many  of  these  cases  of  indigestion  and  nervousness  there 
is  a  condition  of  extreme  lethargy,  while  in  others  the 


270  FUNCTIONAL   NERVOUS   DISOEDERS. 

Opposite  condition  of  sleeplessness  is  frequently  present. 
Women  of  this  class,  as  a  rule,  v,^hen  they  are  in  this  con- 
dition eat  a  sufficiency  of  easily  digested  food,  but  the 
catarrhal  state  of  the  mucous  membrane  of  the  stomach 
and  intestines  interferes  with  its  absorption.  It  not  only 
causes  interference  with  absorption,  but  in  many  cases  it 
causes  decomposition  and  promotes  the  development  of 
poisonous  products.  These,  when  absorbed  into  the  sys- 
tem, irritate  and  depress  the  patient  and  bring  on  the  ner- 
vous manifestations.  So  weak,  languid,  and  easily 
fatigued  do  the  patients  become,  that  they  are  unable  to 
take  the  exercise  necessary  to  rid  the  sj^stem  of  its  waste- 
ash  through  the  emunctories  of  the  bod3^  The  excretion 
of  perspiration  is  insufficient  in  amount,  and  there  is  usu- 
ally chronic  constipation  interrupted  by  intercurrent  at- 
tacks of  diarrhoea. 

I  It  is  well  known  that  some  headaches  are  dependent 
fupon  constipation,  and  that  they  are  often  relieved  by 
cathartic  medication.  Irritation  of  the  vasomotor  nerves 
[of  the  head  from  disturbances  of  the  stomach  or  intestines 
lis  a  common  condition.  Constipation  causes  reflexly  a 
sensation  of  congestion,  and  the  frontal  congestive  head- 
ache is  the  result  of  the  indigestion  and  constipation,  act- 
ing reflexly  or  by  direct  absorption  in  the  intestines.  In 
health  there  is  a  blessed  unconsciousness  of  the  very  exist- 
ence of  a  stomach,  but  let  dyspepsia  be  present  and  the 
patient  can  think  of  little  else.  A  perfect  digestion  gives 
great  energy;  the  blood  circulates  normally  through  the 
brain  and  the  nervous  system,  work,  mental  or  physical, 
is  a  pleasure,  and  life  seems  well  worth  living.  But  the 
dyspeptic  knows  nothing  of  the  joys  of  existence.  A 
shattered  nervous  system  is  all  that  occupies  her  time  and 
thoughts,  and  by  this  constant  introspection  are  brought 


THERAPEUTICS.  271 

about  the  various  conditions  of  neurasthenia,  hysteria,  and 
other  complaints  which  we  have  been  studying.  The 
importance  of  dietetic  treatment  will  thus  be  evident.  It 
is  essential  that  a  definite  plan  be  pursued,  and  there  are 
some  important  points  which  we  must  ever  keep  in  mind. 
We  must  procure  an  effective  elimination  of  all  the  waste 
products  of  the  bod 3'.  First,  we  must  prepare  the  diges- 
tive tract  and  the  tissues  of  the  body  to  receive  and  as- 
similate the  nutriment,  and  then  we  must  select  the  most 
nutritious  food  and  so  prepare  it  that  it  will  be  readil}' 
assimilated.  We  must  remember  to  treat  the  whole  sys- 
tem, which  is  in  a  pathological  condition.  The  most 
rational  method  *of  securing  elimination  through  all  the 
channels  of  the  body  is  by  stimulating  the  activity  of  all 
the  emunctories  by  the  ingestion  of  a  large  quantity  of  hot 
water,  and  by  hot  sponge  baths,  followed  by  a  vigorous 
rubbing  of  the  skin.  This  plan  of  treatment,  to  be  effec- 
tive, must  be  systematically  carried  out,  and  both  physician 
and  patient  must  steadfastly  avoid  that  complete  depend- 
ence on  drugs  which  converts  the  wisest  method  of  treat- 
ment into  blind  empiricism. 

The  causation  of  a  disease  should  be  carefully  studied, 
and  then  by  treating  the  diathesis  the  consequent  disease 
can  be  prevented  or  removed.  Most  of  these  diseases 
depend  for  their  propagation  upon  defects  of  nutrition. 
These  being  removed,  the  disorder  often  disappears.  We 
must  remove  the  cause,  otherwise  the  disease  will  persist 
in  spite  of  all  treatment,  and  to  do  this  a  perfectly  clear 
diagnosis  is  necessary.  It  is  the  bringing  up  of  the  vital- 
ity of  the  patient  that  leads  to  recovery,  as  a  lowering  of 
the  vitality  is  the  first  factor  in  producing  disease. 
Whenever  there  is  vital  energy  there  is  resistance  to  dis- 
ease,.    It  is  a  well-known  fact  that  Nature  has  the  power 


272  FUJ^CTIOXAL   XERVOUS    DISORDERS. 

to  cure  in  most  cases  if  we  give  her  the  materials  to  work 
with,  and  at  the  same  time  stimulate  the  activity  of  the 
emunctories  sufficient^  to  remove  the  poisonous  waste. 

The  diet  for  neurotic  patients  must  be  a  scientific  one, 
based  on  a  knowledge  of  what  the  different  kinds  of  food 
do  for  the  organism.  We  must  provide,  first,  for  the 
oxidation  and  elimination  of  waste  products,  and,  secondly, 
for  scientific  alimenation  with  readily  absorbed  and  easily 
assimilated  nutritive  materials  of  the  highest  grade. 
There  are  many  factors  necessary  for  the  successful  treat- 
ment of  the  neuroses — rest,  mental  and  physical,  pure  dry 
air,  gentle  exercise  in  the  sunshine — all  are  important; 
but  these  are  as  nothing  if  the  nutritioi#  does  not  receive 
proper  attention.  A  knowledge  of  dietetics  is  far  more 
essential  to  success  than  a  knowledge  of  drugs  in  the  treat- 
ment of  either  acute  or  chronic  disease.  A  careful  study 
of  the  physiology  of  digestion  and  assimilation  and  of  the 
composition  and  value  of  the  different  foods  clearly  shows 
us  the  means  by  which  we  are  to  construct  a  diet  of  the 
greatest  utility  to  our  patients.  It  would  seem  as  if  here- 
tofore there  had  been  a  great  lack  of  definite  knowledge  as 
to  the  construction  of  diet  lists.  The  usual  fault  is  that 
there  is  too  great  a  variety  for  each  meal,  and  much  of  it 
is  comparativel}^  difficult  of  digestion.  The  best  argu- 
ment in  favor  of  the  more  enlightened  dietetic  treatment 
of  a  disease  is  to  be  found  in  the  clinical  results.  We 
now  know,  through  a  study  of  physiological  chemistry, 
what  foods  are  of  high  and  what  of  low  nutritive  value ; 
what  ones  are  easily  digested  and  assimilated;  what  re- 
quire special  gland  elaboration  before  their  nutritive  ele- 
ments can  be  utilized;  what  foods  readily  ferment,  and 
what  are  the  causes  of  this  abnormal  change. 

Of  especial  value  are  the  proteid  or  tissue-building  foods, 


THERAPEUTICS.  273 

and  the  one  which  stands  at  the  head  of  the  list,  because 
of  its  utilit}^  in  these  cases,  is  beef.  It  is  difficult  to  show 
the  importance  of  the  selection  of  a  correct  amount  of  the 
different  classes  of  food.  If  a  certain  class  is  taken  in 
excess  there  is  imperfect  assimilation,  and  disease  slowly 
but  surely  results.  I  have  known  fatal  diabetes  to  result 
from  excessive  indulgence  in  raisins.  Oatmeal  mush,  fer- 
menting in  the  intestines,  is  a  common  factor  in  the  pro- 
duction of  nephritis.  A  vegetable  diet  contains  an  injuri- 
ous amount  of  the  carbohydrates  and  too  little  of  the 
proteid  element,  which  in  this  combination  is  difficult  of 
digestion.  That  a  meat  diet,  Avith  a  moderate  proportion  of 
carbohydrates,  is  the  best  food  for  neurotics  lias  been  fre- 
quently demonstrated  clinically.  Milk  has  not  so  great  a 
food  value  as  meat  because  of  its  greater  difficult}"  of  diges- 
tion, its  proneness  to  ferment  because  of  the  sugar  it  con- 
tains, its  lack  of  reparative  material — not  four  jjer  cent,  of 
proteids — and  the  great  danger  of  its  being  impure.  Milk 
may  fatten  and  keep  the  patient  plump,  but  fat  persons 
sometimes  have  tuberculosis  and  are  frequently  neurotic, 
and  much  of  the  fat  we  see  is  unhealthful.  It  is,  neverthe- 
less, of  great  value  as  a  nutrient. 

Bearing  in  mind  the  best  proportions  of  the  three  classes 
of  proximate  principles — viz.,  that  the  amount  of  proteids 
taken  should  exceed  the  amount  of  starchy  food  and  fat — ■ 
it  is  proper  to  consider  how  these  proportions  can  be  ob- 
tained in  a  most  nutritive  and  assimilable  form,  so  that 
while  the  nutrition  is  brought  to  the  highest  point,  elimi- 
nation may  not  be  hindered.  In  the  beginning  of  the 
treatment  the  patient  should  eat  nothing  sweet,  sour,  or 
fried,  and  starchy  and  farinaceous  foods  should  be  entirely 
prohibited,  with  the  exception  of  a  small  quantity  of  stale 

bread  or  boiled  rice,  until  the  digestive  and  lymph  chan- 
18 


274  FUNCTIONAL    NERVOUS    DISORDERS. 

nels  are  entirely  free  from  the  irritating  products  of  fer- 
mentation. In  functional  nervous  disorders  there  is 
usually  a  feeble  digestion  and  frequently  a  low-grade 
catarrhal  and  inflammatory  state  of  the  digestive  tract. 
The  internal  administration  of  hot  water  will  tend  to  re- 
move this  condition  and  restore  the  parts  to  their  normal 
state.  It  is  not  so  much  that  large  quantities  of  food 
should  be  taken,  but  that  it  should  be  thoroughly  assimi- 
lated. The  meat  should  be  lean,  juicy  beef  from  the  cen- 
tre of  the  round;  and,  after  all  the  fat  and  fibre  have  been 
removed,  it  should  be  cut  into  small  pieces  and  passed 
twice  through  a  perfectly  clean  meat  chopper;  or  it  may 
be  scraped  from  the  fibrous  tissue  with  a  knife  or  meat 
scraper,  or  chopped  on  the  block  by  the  butcher.  This 
minute  subdivision  by  grinding  or  chopping  makes  it  most 
digestible.  The  majority  of  patients  have  bad  teeth,  which 
frequently  infect  the  food.  If  the  meat  is  not  thoroughly 
masticated,  the  stomach  certainly  cannot  prepare  it  for 
absorption.  It  should  be  kept  sterile  by  handling  it  with 
perfectly  clean  hands  and  by  cleansing  with  boiling  water 
every  implement  it  touches.  The  pulp  should  now  be 
pressed  very  gently  into  cakes  from  one-half  to  three- 
fourths  of  an  inch  in  thickness.  If  they  are  made  too 
thick,  they  will  be  difficult  to  cook,  and  they  should  not 
be  pressed  too  firmly  together,  as  this  renders  them  less 
digestible  and  less  palatable.  The  cakes  should  then  be 
carefully  broiled  over  a  clear  coal  fire,  or  over  one  free 
from  smoke  and  blaze,  and  they  should  be  turned  fre- 
quently to  retain  the  juice.  If  desirable,  they  can  be  sea- 
soned with  a  little  salt,  pepper,  or  butter. 

Another  method  of  cooking  the  beef  pulp  is  to  gently 
simmer  it  with  a  small  quantit}^  of  water  upon  the  back  of 
the   stove   for   aboiit   twenty   minutes;    it  should   not  be 


THEEAPEUTICS.  275 

allowed  to  boil,  as  this  coagulates  the  albumin,  turning  it 
to  a  gray  color,  and  makes  it  difficult  of  digestion.  This 
dish  is  commonly  known  as  Scotch  collops.  With  this 
meat  diet  a  small  quantity  of  dry,  stale  bread,  two  days 
old,  should  be  taken.  It  should  not  exceed  in  bulk  the 
amount  of  meat  taken.  Beef  tea  of  the  right  kind,  prop- 
erly made,  or  liquid  peptonoids,  may  be  given  for  a  short 
time. 

After  a  time  some  vegetables  can  be  carefully  added  in 
small  quantity,  a  mealy  potato,  or,  as  before  mentioned,  a 
little  boiled  rice,  hominy  or  farina,  sago  or  t&pioca  gruel; 
but  our  main  dependence  must  be  upon  the  beef.  When 
there  is  a  strong  craving  for  more  variety,  the  dietary  may 
be  extended  by  cautiously  adding  a  soft-boiled  egg,  a 
nicely  broiled  tender  steak,  lamb,  mutton,  turke}',  game 
or  chicken,  French  peas  or  string  beans.  The  succulent 
vegetables,  celery,  lettuce,  dandelion,  cauliflower,  and  spin- 
ach, are  sometimes  useful,  as  they  assist  in  overcoming 
the  constipation  that  is  frequently  present. 

Idiosyncrasy  must  be  considered. 

There  are  whole  families  who  cannot  taste  milk  in  any 
form.  I  have  a  patient,  a  young  man  of  twenty,  who  can 
never  taste  tomatoes — even  the  odor  of  sliced  tomatoes 
being  sufficient  to  make  him  sick.  There  are  other  things 
also,  such  as  asparagus  and  cauliflower,  which  it  is  im- 
possible for  him  to  eat,  and  like  many  others,  he  cannot 
eat  Lima  beans  or  yellow  beans.  Articles  having  a  de- 
cided odor  are  exceedingly  distasteful  to  him.  He  has 
never  eaten  butter  and  cannot  take  it  in  any  form,  either 
fresh  or  salt,  without  it  causing  excessive  nausea.  These 
neuroses,  as  they  may  be  termed,  of  the  gustatory  nerve 
are  often  really  psychoses  and  are  exceedingly  common. 
Many  of  our  ordinary  articles  of  diet  are  taken  as  the  re- 


276  FUNCTIOlSrAL   NERVOUS    DISORDERS. 

suit  of  an  acquired  taste.  This  is  particularly  the  case 
with  tomatoes,  Liaia  beans,  oyster  plant,  parsnips,  carrots, 
and  turnips.  Many  persons  cannot  eat  butter  on  bread, 
even  when  extremely  hungry,  without  being  nauseated. 
Again,  some  individuals  never  eat  salt,  while  others  take 
inordinate  quantities.  In  these  cases  there  is  always 
digestive  derangement  and  generally  decomposition  of 
starchy,  saccharine,  and  fatty  articles  of  diet.  In  the 
foregoing  regimen  these  have  been  excluded  to  a  great 
extent.  If  constipation  be  present,  a  little  Turkish  rhu- 
barb, or,  better  still,  a  small  glass  of  senna  tea,  with  an 
aromatic  such  as  fennel  to  obviate  griping,  or  a  teaspoon- 
ful  of  table  salt  in  a  glass  or  two  of  cold  water,  may  be 
taken  on  going  to  bed  or  on  rising.  Bad  cooking  and  in- 
digestible food,  like  cheese,  pastry,  baked  beans,  corn, 
lobsters,  clams,  pork,  greasy  macaroni,  sausage,  cabbage, 
pickles,  porridge  or  mush,  hard-boiled  eggs,  salads,  veal, 
doughnuts,  nuts,  raisins,  raw  onions,  cucumbers,  fruits, 
and  impure  milk  should  be  carefully  avoided.  To  this 
may  be  added  strong  tea  and  coffee,  especially  the  latter. 

As  regards  liquids,  the  patient  may  be  allowed  to  drink 
a  cup  of  properly  prepared,  thick,  home-made  beef  tea,  or 
the  expressed  juice  of  beef  every  two  or  three  hours,  if 
very  weak;  otherwise  only  at  meals.  Peptonized  milk,  or 
milk  and  Highland  water,  or  cocoa,  or  very  weak  tea, 
may  also  be  taken  for  a  change,  but  without  sugar. 

The  patient  should  have  a  table  to  himself  or  eat  alone; 
otherwise  there  will  be  a  temptation  to  indulge  in  articles 
not  permitted.  When  the  appetite  increases  very  much, 
four  meals  may  be  taken  daily,  if  needed,  but  at  regular 
hours,  the  last  one  not  to  be  later  than  seven  o'clock.  It 
is  not  well  for  the  physician  to  be  too  strict  in  regard  to 
diet,  nor  prejudiced  against  certain  foods,  as  individuals 


THERAPEUTICS.  277 

vary.  The  meals  should  be  simple,  and  confined  to  a  few 
articles,  the  fewer  the  better. 

Elimination  of  the  diseased  products  is  of  extreme  im- 
portance in  all  acute  and  chronic  diseases.  When  the 
vitiated  matter  is  removed  by  elimination  the  disease  can- 
not be  so  severe,  as  then  there  is  an  internal  asepsis  which 
prevents  bacillary  development.  The  eliminating  organs 
should  be  stimulated,  and  hot  water  is  the  blandest  and 
most  efficacious  means  of  accomplishing  it  through  the 
kidneys.  A  glass  or  two  of  hot  water  should  be  taken  an 
hour  or  two  before  meals,  and  half  an  hour  before  retiring, 
and  enough  fluid,  preferably  water,  with  the  meals  to 
assist  digestion  and.  absorption.  It  would  be  well  if  hot- 
water  shops  were  as  common  in  this  country  as  in  China ; 
they  would  to  a  degree  be  a  substitute  for  the  liquor  stores, 
and  would  accomplish  the  same  purpose  in  removing  in- 
ternal cravings  and  stimulating  the  patron  without  intox- 
icating him. 

After  elimination  the  next  important  step  is  to  build  up, 
when  possible,  the  diseased  and  broken-down  tissues. 
This  is  accomplished  by  stimulating  the  manufacture  of 
pure,  fresh  blood. 

In  neurotics,  there  being  an  excess  of  waste,  we  must  be 
careful  to  get  the  proper  quantities  and  proportions  of  pro- 
teid  and  carbohydrate  foods,  and  have  the  waste  products 
completely  oxidized.  When  fresh  meat  is  taken  there  is 
an  increase  in  the  red.  corpuscles — the  oxygen  carriers — 
but  there  is  a  limit  to  the  quantity  of  food  that  can  be  oxi- 
dized. Ordinarily,  we  take  too  much  carbohydrate  food, 
and  our  meats  (proteids)  are,  except  in  the  largest  cities 
and  among  the  more  intelligent,  usually  improperly  cooked 
— most  generally  fried.  It  is  the  taking  of  excessive 
quantities  of  indigestible  and  stimulating  foods  that  causes 


278  PUNCTIONAL   XERVOUS    DISORDERS. 

disease.  To  maintain  the  highest  standard  of  health, 
more  of  meat  tlian  of  vegetable  food  should  be  taken. 
Carnivorous  or  meat-eating  animals  seldom  have  con- 
sumption, while  it  is  quite  common  in  the  herbivorous  or 
vegetable-eating  animals.  The  greater  "  vitality"  or  activ- 
ity of  the  former  as  compared  v^^ith  the  latter  is  worthj'^  of 
note. 

The  fallacies  of  a  purely  vegetable  diet  are  most  com- 
monly demonstrated  by  the  bedside  of  the  patient.  Such 
a  diet  requires  a  greater  amount  of  oxygen  and  more  ex- 
tensive elaboration  by  the  glandular  structures  of  the  body, 
and  results  in  an  excess  of  waste,  which  must  be  excreted. 
I  have  seen  nephritis  developed  by  the  excessive  indulgence, 
in  cereal  and  fried  foods.  Milk,  although  almost  univer- 
sally recommended,  is  not  a  good  exclusive  diet  for  a  con- 
sumptive. It  is  all  right  for  small  children  and  babies,, 
who  simply  require  to  be  kept  warm  with  fattening  food. 
Experience  has  taught  me  that  a  meat  diet  is  far  prefer- 
able for  adults.  It  is  a  concentrated  and  most  nutritious 
food,  and  withal  is  easy  of  digestion.  In  Japan  there  are 
scarcely  any  cows,  yet  the  people  are  in  good  health. 

In  treating  neurotics  we  should  give  attention  to  both 
the  liver  and  the  lungs.  We  should  restore  the  biliary 
secretion  to  a  healthy  standard,  both  as  to  quality  and 
quantity.  From  our  standpoint  the  liver  is  the  most  im- 
portant organ,  for  by  its  defective  elaboration  of  food  pro- 
ducts nutrition  is  impaired,  and  anaemia  and  disease  result. 
Overfeeding  and  improper  feeding  tend  to  imperfect  elabo- 
ration and  elimination  by  giving  the  liver  and  kidneys  too. 
much  work  to  perform. 

I  do  not  discard  milk  in  cases  of  neurasthenia  and  other 
functional  diseases,  but  I  think  too  much  reliance  has  been 
placed  upon  it  alone  as  a  reconstructive  tissue  food.     There. 


THERAPEUTICS.  279 

are  many  who  say  they  cannot  take  milk,  but  the  stomach 
can  be  trained  to  receive  it  and  in  a  short  time  to  relish  it. 
A  very  small  quantity  should  be  given  at  first.  It  should 
be  remembered,  however,  that  milk  has  been  shown  to 
contain  a  number  of  parasites  and  bacteria. 

In  these  diseases  the  increased  digestion  of  nitrogenous 
food  is  our  sheet  anchor,  and  when  this  is  inadequate 
there  is  no  arresting  the  progress  of  these  maladies.  Even 
in  cyses  in  which  the  lungs  are  involved  the  progress  of  the 
disease  can  be  permanently  arrested,  if  too  much  tissue 
has  not  been  destroyed.  While  nothing  gives  such  good 
results  as  dietetic  treatment,  aided  by  medicines,  a  careful 
preparation  of  the  digestive  tract  and  its  appendages 
should  not  be  omitted.  This  not  only  removes  catarrhal 
and  inflammatory  states,  but  gives  tone  and  strength  to 
the  muscular  and  nervous  systems,  stops  diarrhoea,  nausea, 
and  fever,  restores  the  appetite,  and  increases  and  enriches 
the  blood  supply.  Such  treatment,  when  combined  with 
proper  climate  and  other  hygienic  and  medicinal  remedial 
measures,  brings  back  health  and  vigor  to  many  an  appar- 
ently hopeless  neurasthenic. 

The  following  rules  should  not  be  regarded  as  infallible 
and  absolute  guides,  but  serve  as  important  hints,  the 
application  of  which  the  attending  physician  will  point 
out: 

(1)  Be  careful  to  eat  enough,  but  not  too  much.  It  is 
said  that  the  majority  of  persons  eat  too  much.  I  am  sure 
there  are  a  vast  number  who  eat  too  little.  Use  great  care 
as  to  the  quality  and  kind  of  food  taken. 

(2)  Do  not  eat  too  rapidly  or  drink  too  much  liquid 
during  the  meal,  as  this  tends  to  imperfect  mastication 
and  to  bolting  the  food. 

(3)  Do  not  take  a  great  variety  at  each  meal,  but  con- 


280  FUNCTIONAL    XERYOUS    DISORDERS. 

tent  yourself  with  a  few  articles  of  the  simplest  and  most 
nutritious  kind,  such  as  stale  white  bread,  boiled  rice, 
homin}-,  or  farina;  fresh  beef,  mutton,  or  lamb;  fresh  fish, 
oysters,  mealy  baked  or  boiled  potatoes,  celery,  cauli- 
flower, spinach,  lettuce,  tomatoes. 

(4)  Do  not  use  strong  tea,  coffee,  or  stimulants  unless 
specially  permitted.  Eat  nothing  sweet,  sour,  or  fried. 
Meats  should,  be  fresh  and  of  the  best  qualit3\  They  are 
best  broiled  rare,  and  should  be  eaten  hot.  Beef  and  mut- 
ton, if  not  broiled  or  roasted,  should  be  stewed  until  very 
tender.  Eggs  should  be  poached  or  soft  boiled.  Corn 
bread,  as  a  rule,  is  made  too  sweet,  otherwise  it  is  very 
wholesome.  No  saleratus  biscuits,  hot  or  cold,  or  pancakes, 
except  on  rare  occasions,  should  be  taken.  Rice,  hominy, 
farina,  cracked  wheat,  and  cornmeal  can  be  used. 

Occasionally,  after  the  patient  becomes  somewhat 
stronger,  strained  oatmeal  gruel  can  be  taken.  It  is  best 
cooked  in  a  water  bath ;  that  is,  a  vessel  for  the  purpose 
set  in  a  pot  of  boiling  water.  This  prevents  it  from  burn- 
ing. It  should  cook  for  several  hours.  It  can  be  used 
with  milk  or  cream. 

For  drinking  purposes  nothing  equals  good,  pure  soft 
water,  from  a  granite  or  trap-rock  region.  If  the  stomach 
is  tender,  it  is  an  excellent  plan  to  sip  slowly  a  glass  of  hot 
water  half  an  hour  before  meals  or  during  the  meal,  with 
a  little  milk  added  to  give  it  color.  Cacao  is  digestible 
and  strengthening.  Skim  milk  is  also  useful,  and  is  best 
taken  hot. 

As  it  is  difficult  for  the  patient  to  remember  lengthy 
verbal  statements,  especially  when  also  the  exact  dosage 
and  manner  of  taking  the  drugs  prescribed  must  not  be 
forgotten  and  is  alwaj's  considered  by  them  of  the  greatest 
importance,  any  of  the  following  articles  of  diet  or  the 


THERAPEUTICS. 


281 


rules  which  are  necessary  in  the  treatment  of  the  case  can 
be  underlined  or  pen-marked  at  the  side  of  a  prepared  list: 


Beef. 

Mutton. 

Lamb. 

Chicken. 

Turkey. 

Duck. 

Game. 

Beef  tea  (thick). 

Mutton  broth  (thick) . 

Chicken  broth  (thick). 

Liver. 


Eggs  (poached  or  soft-boiled) . 

Oysters. 

Fresh  fish. 

Butter. 

Buttermilk. 

Thick  milk. 

Sweet  milk. 

Kumyss. 

Soups. 

Milk  puddings. 

Custard. 


White  wheat  bread  (stale). 

Brownbread. 

Roasted  bread. 

Toast. 

Corn  bread. 

Crackers. 

Rice. 

Hominy. 


Potatoes  (white). 

Potatoes  (sweet). 

Peas  (tender). 

Beans  (white). 

Beans  (Lima). 

Spinach. 

Celery. 

Cauliflower  (boiled). 

Cabbage  tops  (tender) . 

Lettuce. 

Cacao. 
Chocolate. 
Caramel  coffee. 
Lemonade. 


Farina. 

Cracked  wheat. 

Cornraeal  mush. 

Macaroni. 

Cornstarch  pudding. 

Germea. 

Arrowroot. 


VEGETABLES,    FRUIT. 


DRINKS. 


Tomatoes. 

Onions. 

Bananas. 

Melons.  » 

Peaches. 

Grapes. 

Prunes. 

Apples  (baked  or  stewed) . 

Oranges. 


Whey. 

Chicken  broth. 
Beef  tea. 
Mineral  waters. 


The  food  question  recurs  three  times  every  day  and  is 
an  important  one.     There  are  many  nervous  patients  who 


282  ruNCTios"AL  xervous  disorders. 

do  not  take  enough  food,  fearing  that  it  will  not  be  digested 
and  cause  distress  from  pain  and  flatulence.  Some  of 
these  patients  have  a  great  many  dislikes,  which  thus  cur- 
tail the  variety  of  food  greatl}^  so  much  so  that  it  is  com- 
mon to  find  them  in  a  state  of  partial  inanition.  Often- 
times they  are  quite  hysterical  on  this  point.  Much  of 
the  food  they  prefer  is  indigestible  or  made  so  by  improper 
cooking.  Gradually  the  dietary  of  these  patients  should 
be  enlarged,  especiall}^  the  fresh  meat  portion  of  it,  until 
suflScient  is  taken  to  supply  the  actual  needs  of  the  body. 
As  a  rule,  stimulants  of  all  kinds  should  be  forbidden.  In 
certain  cases  it  is  desirable  that  four  or  even  five  meals 
should  be  taken  daih',  but  these  should  not  be  large,  as 
the  patient  might  thus  overeat.  The  following  is  a  sam- 
ple of  what  might  be  taken : 

Breakfast,  8  to  9.  Hominy,  rice,  farina,  or  arrowroot, 
with  rich  milk  or  cream;  two  or  three  small  chops,  with  a 
slice  or  two  of  bread  and  butter;  a  glass  of  water,  hot  or 
cold,  after  the  meal. 

About  eleven  or  twelve  o'clock  a  cup  of  beef  tea  or  a 
glass  of  milk  and  a  cracker  can  be  taken,  if  the  patient  is 
hungry. 

Luncheon,  1  to  2.  Fresh  meat  or  fish,  either  roast, 
broiled,  or  boiled.  Beef,  mutton,  or  lamb;  mashed  or 
well-baked  potatoes;  some  green  vegetables,  such  as  let- 
tuce, celery,  caulifiower,  or  tomatoes;  finally  a  plain  milk 
pudding,  with  a  cup  of  weak  tea,  cacao,  or  milk. 

Supper.  Fresh  fish,  soft-boiled  eggs,  chicken,  or  tm"key, 
bread  and  butter ;  a  glass  of  cold  or  hot  water  containing 
a  little  milk. 

On  retiring  a  cup  of  beef  tea,  cacao,  or  chocolate,  agree- 
ably prepared,  may  be  taken  if  desired.  If  wines  are 
desired,  a  small  glass  of  claret  or  Burgundy  may  be  taken 


THERAPEUTICS.  283 

at  luncheon.     As  a  rule,  patients  do  better  without  alco- 
holic stimulants. 

When  there  is  a  condition  of  great  nerve  exhaustion, 
placing  the  patient  away  from  friends  and  relatives  in  a 
properly  conducted  sanatorium  is  of  marked  benefit. 

On  entering,  a  very  careful  physical  examination 
should  be  made  and  recorded.  This  should  include  the 
patient's  weight  and  dynamometer  strength  of  the  impor- 
tant muscles. 

The  Weir  Mitchell  plan  of  treatment  is  often  of  great 
benefit  to  these  patients.  About  four  ounces  of  milk 
should  be  given  every  two  hours  while  the  patient  is 
awake,  but  they  should  not  be  awakened  to  take  it,  the 
quantity  should  be  gradually  increased  until  at  least  two 
quarts  are  taken  daily.  If  it  disagrees  and  makes  the  pa- 
tient "bilious,"  a  little  salt  or  some  lime  water  should  be 
added  to  it,  after  diluting  it  with  boiling  water.  After  a 
few  days  plain  nutritious  foods  can  gradually  be  added, 
until  a  full  diet  supplements  the  milk  taken.  After  a  time 
the  superalimentation  can  be  gradually  reduced  and  open- 
air  physical  curative  exercise  indulged  in  to  a  great  ex- 
tent. 

All  dietetic,  general,  tonic,  or  other  treatment  is  useless 
unless  there  is  a  plentiful  supply  of  pure  air.  Pure  air  is 
a  great  stimulant  to  the  appetite  and  digestion  by  reason 
of  the  oxygen  which  it  contains.  The  rooms  occupied  by 
the  sick  person  should  therefore  be  carefully  ventilated, 
without  producing  draughts,  and  in  cold  weather  should  be 
filled  with  a  genial  warmth.  The  patient  should  be  out  of 
doors  as  much  as  possible  when  the  weather  is  not  too 
severe.  Oxygen  should  be  forced,  so  to  speak,  into  the 
lungs  by  an  atomizer  attached  to  an  air  compressor.  It  is 
the  sine  qua  non  in  all  nervous  and  lung  diseases.     It  can 


284  FUNCTIONAL    NERVOUS    DISORDERS. 

also  be  used  in  the  form  of  pyrozone,  or  peroxide  of  hydro- 
gen, properly  diluted  for  inhalation  or  the  spray. 

Gentle  and  systematized  exercise,  without  fatigue,  has  a 
very  beneficial  effect  upon  nutrition  by  stimulating  the 
action  of  the  heart,  accelerating  the  circulation,  and  in- 
creasing the  respiration.  It  thus  increases  the  oxidation 
of  waste  products  and  leaves  room  for  the  assimilation  of 
nutriment.  For  the  weak,  a  daily  carriage  ride  is  bene- 
ficial, and  for  those  who  cannot  afford  this  the  street 
cars  can  be  utilized.  Boat  rides  on  bays,  lakes,  or  rivers, 
and  sea  voyages  are  also  often  very  beneficial;  but  the 
invalid  must  be  well  wrapped  up.  For  those  who  are 
able,  walking  in  moderation  is  a  very  useful  form  of 
exercise. 

Voluntary  exercise  is  best  given  in  the  form  of  scientific 
gymnastics  under  a  competent  medical  instructor,  and  it 
should  be  carried  to  the  point  of  moderate  fatigue  of  the 
muscles  used,  but  no  farther. 

The  arms  and  chest  muscles  are  especially  to  be  exer- 
cised, and  this  is  accomplished  by  light  dumbbells. 

If  the  patient  is  extremely  weak,  passive  exercise  by 
Swedish  movements  or  massage  may  be  given.  For  con- 
stipation and  indigestion  local  abdominal  massage  should 
be  employed. 

In  certain  institutions,  sanatoriums,  and  schools  of  phys- 
ical culture  passive  exercise  is  given  in  a  perfected  man- 
ner. Properly  performed,  it  is  of  great  value  to  nervous 
invalids.  The  rubbing,  pressing,  and  shampooing  which 
the  muscles  get  strengthens  them  without  calling  for  any 
nerve  expenditure.  The  skin  is  nourished,  hardened,  and 
strengthened  by  the  same  process.  Under  it,  combined 
with  the  muscular  exercise  and  the  shower,  the  obese  lose 
fat  and  the  lean  grow  plump  from  a  new  development  of 


THERAPEUTICS.  285 

healthy  muscular  tissue.  It  would  seem  to  be  as  neces- 
sary to  groom  the  human  animal  as  it  is  the  horse.  The 
result  is  about  the  same ;  both  thrive  under  it.  Not  every 
nurse  or  operator  can  give  passive  exercise  in  a  proper 
manner.  It  requires  a  special  knowledge  and  training. 
As  a  remedial  measure  it  is  adapted  to  many  disorders  of 
the  nervous  system.  The  best  time  for  its  application  is 
immediately  after  the  showerbath,  and  it  may  be  given 
in  some  cases  twice  a  day.  After  the  body  has  been  well 
dried  the  frictions  with  the  hand  or  bath  glove  should  be 
systematically  given  to  all  parts  of  the  body.  The  muscles 
and  parts  that  are  weak  and  require  it  should  be  especially 
worked  under  the  fingers,  and  all  dampness  and  coldness 
removed  by  the  stimulating  healthy  effect  of  the  frictions 
upon  the  circulation.  Many  other  motions  are  used,  such 
as  kneading  and  tapotement  or  percussions,  and  the  nutri- 
tion of  the  body  is  much  improved  as  a  consequence.  A 
good  time  for  the  exercise  is  early  in  the  morning  before 
breakfast,  or  three  or  four  hours  after  a  meal.  After  the 
exercise  the  patient  should  rest  for  at  least  an  hour  if 
possible. 

The  curative  exercise  and  massage  ought  to  take  from 
thirty  to  ninety  minutes,  according  to  the  condition  of  the 
patient. 

The  skin  should  assist  in  the  work  of  elimination  and 
protection.  Cool  or  cold  sponge  baths,  according  to  the 
vitality  of  the  patient,  have  a  most  salutary  effect.  A  fine 
shower  is  preferable  to  the  sponge  or  dip.  Its  duration 
should  be  exceedingly  brief,  and  after  it  the  skin  should  be 
rubbed  dry  with  coarse  towels.  Assisted  by  the  patient 
herself,  the  bath  should  be  taken  in  a  room  of  mild  tem- 
perature. Followed  by  massage,  the  cool  bath  is  one  of 
the  greatest  nerve  and  brain  tonics  known.     A  hot  sponge 


286  FUNCTIOXAL    XERVOUS    DISOEDERS. 

bath,  with  a  little  kretol  added,  should  be  taken  at  night, 
and  the  body  should  be  vigorously  rubbed  afterward.  If 
there  is  a  tendency  to  "catching  cold,"  the  body  may  be 
Avell  rubbed  with  some  nutritive  oil. 

In  order  to  sleep,  the  mind  should  be  kept  from  exciting 
occupation,  especially  toward  evening.  The  room  should 
be  well  ventilated  and  the  bed  comfortable.  The  evening 
meal  should  be  light  and  simple,  and  no  food  should  be 
taken  as  a  rule  immediately  before  retiring.  Care  should 
also  be  taken  to  avoid  stimulants.  An  abundance  of  un- 
disturbed sleep  is  of  vital  importance  to  nervous  invalids. 
They  should  retire  promptly  at  ten  o'clock,  if  not  before. 
The  importance  of  improving  the  nutrition  of  the  neurotic 
is  acknowledged  by  all  physicians.  By  careful  attention 
to  the  foregoing  method  the  quality  of  the  blood  and  the 
general  nutrition  of  the  body  are  greath''  improved.  Mal- 
nutrition in  all  degrees  is  found  among  the  nervous,  and 
especially'  those  suffering  from  neuralgia.  The  rational 
treatment  for  such  cases  is  to  fill  the  blood-vessels  with 
blood  rich  in  nutritive  materials  to  feed  the  impoverished 
nerves,  as  starvation  is  at  the  foundation  of  most  of  the 
nervous  ills.  Most  of  the  cases  result  from  anxiety,  im- 
proper diet,  and  deficient  sleep.  It  is  not  so  much  work 
as  worry  that  does  the  damage.  Forced  feeding,  as  a 
sequence  to  muscular  exercise  in  a  pure  atmosphere,  and 
mental  as  well  as  physical  rest  are  what  is  needed.  When 
this  is  properl}'  carried  out  the  patients,  as  a  rule,  rapidly 
recover.  It  is  a  simple  means  of  treatment,  yet  a  success- 
ful one.  In  severe  cases  isolation,  change  of  scene,  and 
electro-therapy  may  be  required.  Outdoor  exercise  is  very 
beneficial  to  all  nervous  invalids. 

Flannel  garments,  of  a  thickness  suitable  to  the  season, 
should  be  worn.     It  would  be  difficult  to  get  them  too 


THERAPEUTICS.  28? 

"thick  for  our  severe  winters.  In  cold  weather  the  stock- 
ings should  be  of  wool. 

Corpulence. — Neurasthenic  patients  who  suffer  from 
corpulence  may  experience  much  benefit  by  excluding  for 
a  short  time  from  their  diet  all  fatty  foods,  or  those  that 
are  converted  into  fat,  such  as  sugar  and  farinaceous 
foods,  bread,  potatoes,  beets,  parsnips,  carrots,  turnips, 
rice,  hominy,  beans,  peas,  and  substituting  spinach,  cel- 
ery, tomatoes,  lettuce,  cauliflower,  greens,  cabbage  free 
from  stems,  buttermilk,  skimmed  milk,  oysters,  eggs  and 
meat,  except  pork  or  veal.  All  vegetables  grown  under- 
ground should  be  avoided. 

A  lean-meat  diet  is  essential  in  this  affection,  but  it 
must  be  properly  prepared,  otherwise  the  patient  will  soon 
get  disgusted  and  abandon  it.  Properly  prepared,  and  in 
proper  quantities,  it  can  readily  be  taken  for  a  long  period 
with  a  relish. 

The  modes  of  preparing  and  cooking  meat  which  have 
already  been  given  may  be  used  in  the  case  of  corpulency, 
and  the  following  additional  recipes  will  be  found  advan- 
tageous. 

Methods  of  Cooking  the  Ground  Meat. — Scotch  col- 
lops:  Put  one  pound  of  chopped  or  ground  beef  in  a 
stew-pan  and  add  enough  cold  water  to  cover  the  meat; 
add  an  onion  cut  up  fine  and  a  little  salt  and  black  pepper. 
Simmer  carefully  on  the  back  of  the  range  (it  must  not  be 
allowed  to  boil) ;  add  a  little  sauce  free  from  red  pepper 
shortly  before  serving,  and  garnish  with  small,  thin  pieces 
of  roasted  bread,  not  too  crisp  or  hard. 

The  following  is  another  way  of  cooking  the  chopped 
meat,  is  very  pleasant  for  a  change,  and  when  so  pre- 
pared it  is  easily  digested  : 

Take  one  pound  and  a  half  of  chopped  or  ground  beef, 


288  FU]N'CTIONAL   NERVOUS    DISORDERS. 

one  pint  of  good  meat  soup,  free  from  fat;  simmer  care- 
fully over  a  gentle  fire  until  well  cooked.  It  must  not 
boil,  as  this  coagulates  the  albumin,  interfering  with  its 
digestibilit}^  and  its  value  as  nourishment.  This  is  more 
palatable  than  the  beef  cakes,  even  when  they  are  soaked 
in  meat  soup  before  broiling. 

A  nice  dish  for  a  change  is  to  take  some  stock  and  a 
little  boiled  milk,  and  add  one-third  the  quantity  of  bread 
crumbs  to  the  chopped  beef,  mixing  well  together  and  mak- 
ing into  soft  cakes  about  three-quarters  of  an  inch  thick. 
Brush  over  them,  beaten  white  of  egg  and  broil  carefully 
over  a  clear  coal  fire. 

Still  another  way  is  to  broil  the  meat  slightly,  pass  it 
through  the  meat  chopper,  and  then  mix  it  with  good 
meat  soup  free  from  grease  and  simmer  carefully  until 
cooked  over  a  gentle  fire,  being  careful  not  to  let  it  boil. 
This  is  very  nourishing. 

Frequent  bathing,  especially  Turkish  baths,  accompa- 
nied by  vigorous  massage,  walking,  exercise,  or  bicycle 
riding,  must  be  taken.  Cold  water  and  kretol  baths  of 
short  duration  have  a  delightfully  stimulating  effect  upon 
the  skin.  Large  quantities  of  fresh  air  should  be  inhaled 
to  oxidize  the  excess  of  fat,  which  the  hot  water  then 
eliminates. 

With  the  above  is  combined  the  medical  treatment,  con- 
sisting of  the  chlorate  and  iodide  of  potassium  as  oxidi- 
zers, and  such  other  remedies  as  are  indicated  and  usually 
prescribed. 

The  physician  should  make  such  modifications  in  the 
diet  as  the  condition  of  the  patient  requires. 

Much  of  the  food  eaten  not  being  digested,  it  undergoes 
fermentation,  evolving  yeast,  carbonic  acid  gas,  vinegar, 
or  alcohol.     Instead  of  nourishing  the  body,  a  catarrhal 


THERAPEUTICS.  289 

state  of  the  digestive  organs  is  the  result  of  this  fermenta- 
tion, and  a  diseased  condition  of  the  tissues  of  the  body 
supervenes. 

In  perfect  health  the  normal  amount  of  adipose  tissue 
should  not  exceed  five  per  cent  of  the  total  w^eight  of  the 
body.  Obesity  is  due  usually  to  defective  oxidation  of  the 
excess  of  food  taken,  and  of  the  waste  of  the  body  gener- 
ally. It  is  a  disease  process  resulting  from  eating  to  ex- 
cess of  all  kinds  of  food,  and  especially  those  that  form 
fat.  Excessive  use  of  alcoholic  beverages  and  lack  of  ex- 
ercise in  the  o]3en  air  are  also  great  factors  in  its  produc- 
tion. It  is  simply  the  outcome  of  wrong  physical  habits, 
and  especially  improper  alimentation.  The  difficulty  of 
breathing,  the  great  enlargement  of  the  body,  and  interfer- 
ence with  easy  movements  are  the  principal  symptoms 
which  attract  the  attention  in  this  condition. 

The  cure  of  this  disease  is  safe  and  rather  simple  by  a 
rigid  adherence  to  a  proper  dietary.  In  a  comparatively 
short  time,  as  a  result  of  the  treatment,  the  digestive  or- 
gans are  restored  to  a  healthy  state.  In  a  very  extensive 
experience  during  the  last  ten  years  with  this  plan  of 
treatment,  I  have  seen  that,  when  honestly  carried  out  as 
advised,  it  has  usually  been  successful,  and  has  never  been 
productive  of  anything  but  good  to  the  patient,  as  it  is 
based  upon  scientific  principles. 

Special  feeding  is  here  indicated  by  the  condition  of 
the  system,  and  acts  as  a  means  of  cure  in  this  disease, 
which  has,  as  a  rule,  resulted  from  unhealthy  feeding. 

The  hot  water  should  be  carefully  taken  as  advised,  as 

it  is  a  most  important  part  of  this  method  of  treatment. 

The  action  of  hot  water  in  the  stomach  and  intestines  has 

already  been  fully  discussed.     It  should  be  quite  hot,  but 

still  of  a  comfortable  temperature — anywhere  between  110° 
19 


290  FUNCTIONAL   NERVOUS    DISORDERS. 

and  130°  F. — and  not  simply  warm,  as  warm  water  nau- 
seates. It  may  be  slightly  disagreeable  to  take  at  first, 
but  one  soon  gets  accustomed  to  it.  A  pinch  of  salt  or  a 
few  drops  of  lemon  juice  may  be  added  if  desired.  Many 
physicians  advise  almost  complete  abstention  from  liquids, 
but  it  seems  to  me  that  this  is  a  dangerous  procedure  and 
liable,  from  the  non -elimination  of  the  poisonous  waste  of 
the  body,  to  cause  arterial  and  renal  disease. 

When  digestion  and  assimilation  are  much  interfered 
with,  as  in  this  disease,  the  diet  of  ground  or  chopped 
beef  is  indicated,  it  being  very  easy  of  digestion  and  as- 
similation. It  is  rapidly  absorbed  and  enriches  the  blood, 
which  is  always  in  this  disease  deficient  in  the  oxygen 
carriers  (the  red  blood  corpuscles) .  Carefully  broiled,  ten- 
der steak  is  nearly  as  useful  as  the  ground  beef,  but  it 
should  be  well  masticated.  Although  it  is  not  a  fattening 
diet,  it  is  very  strengthening,  making  the  weak  happier 
and  more  comfortable  as  a  result  of  their  renewed  health. 

This  is  a  hard  diet,  and  a  great  deal  of  self-denial  and 
perseverance  will  be  necessary.  It  is  best  to  eat  alone  and 
yet  be  in  the  room  with  company.  Thus  the  temptation 
to  indulge  in  forbidden  articles  of  food  is  avoided.  If 
there  is  a  feeling  of  weakness  or  insomnia  at  night,  drink 
a  little  beef  tea,  or  have  a  sandwich  or  cracker  at  hand. 
In  beginning  the  treatment  the  patient  may  feel  a  trifle 
weaker  in  body  for  a  day  or  two,  owing  to  the  absence  of 
the  products  of  fermentation,  alcohol,  etc.,  but  this  is  nat- 
ural and  to  be  expected .  The  patient  should  at  first  keep 
quiet,  and  he  will  rapidly  grow  strong  and  his  mind  will 
feel  stronger  and  clearer.  There  will  immediately  begin  a 
shrinkage  in  weight  as  the  diseased  fat  disappears.  Out- 
of-door  exercise  should  be  taken — Avalking,  bathing,  dumb- 
bell exercise  for  ten  minutes,  three  times  daily,  three  hours 


THERAPEUTICS.  291 

after  meals.  As  a  rule  all  stimulants  are  forbidden,  ex- 
cept as  specially  ordered  by  the  physician. 

Obesity  is  simply  a  disease,  and  must  be  treated  as 
such.  The  fat  accumulates  because  it  is  not  oxidized. 
Alcohol,  taken  as  a  beverage  and  generated  in  the  intes- 
tine by  fermentation  of  starchy  food,  interferes  to  a  marked 
extent  with  oxidization. 

The  following  bill  of  fare  will  be  found  to  be  au  excel- 
lent one  in  these  cases : 

Breakfast.  Four  to  five  ounces  of  chopped  beef, 
chicken,  mutton,  or  game,  or  broiled  white  fish.  One 
large  cup  of  weak  tea,  without  milk  or  sugar. 

Dinner.  Five  or  six  ounces  of  any  white  fish  except 
herring  or  eels ;  any  kind  of  poultry  or  game ;  any  meat 
except  pork  or  veal;  a  biscuit  or  a  slice  of  stale  bread; 
a  tablespoonful  of  liquid  peptonoids  in  water. 

Supper.  Three  or  four  ounces  of  chopped  beef,  chicken, 
and  two  small  slices  of  stale  bread. 

A  pint  of  hot  spring  water  should  be  sipped  at  intervals 
every  two  hours.  As  a  laxative,  when  needed,  a  wine- 
glassful  of  senna  tea,  with  a  little  fennel  added,  may  be 
taken. 

Assimilation. — By  the  term  assimilation  is  meant  the 
phenomena  of  the  incorporation  of  food  taken  by  living 
beings  into  their  own  tissues.  This,  in  other  words,  is  a 
storing  up  of  products  to  be  used  in  the  development  of 
energy,  with  the  resultant  formation  of  waste  products. 
The  latter  are  thrown  off  by  the  excretory  organs,  i.e., 
the  bowels,  kidneys,  lungs,  and  skin. 

Of  the  substances  used  as  food,  water  is  the  most  im- 
portant. The  processes  of  digestion,  absorption,  and  tissue 
metabolism  cannot  go  on  without  it.  One  can  survive 
upon  it  longer  than  upon  any  other  single  alimentary  prin- 


293  FUNCTIONAL   NERVOUS   DISOEDEES. 

ciple;  it  is  not  only  food,  bnt  a  digestive  agent  as  well, 
and  constitutes  from  fifty-eight  to  seventy  per  cent,  (ac- 
cording to  different  authorities)  of  the  body  weight.  The 
various  substances  destined  for  excretion  require  water  for 
their  solution,  especially  so  in  the  urine.  The  water  for 
drinking  is  usually  obtained  from  springs,  although  river 
waters,  which  are  less  pure,  are  frequently  used  for  this 
purpose.  Granite-rock  water  (of  which  the  Highland 
water  is  a  good  example)  constitute  the  best  class  of  po- 
table waters;  next  come  the  trap-rock  waters.  The  spar- 
kling lime-rock  waters,  like  Apollinaris,  are  also  palatable 
and  pleasant  to  use,  but  not  quite  so  digestible  as  the 
former.  A  good  drinking-water  should  not  be  too  hard ; 
it  should  be  colorless  and  without  odor.  When  there  is 
the  slightest  suspicion  in  regard  to  its  purity,  it  should  be 
thoroughly  tested  to  see  that  it  is  free  from  organic  matter 
in  a  state  of  decomposition,  as  many  of  our  most  fatal  dis- 
eases, such  as  typhoid  fever,  cholera,  and  dysentery  come 
to  us  through  the  w^ater  supply.  Milk,  or  some  of  its 
preparations,  while  a  complete  food  for  infants,  is  not  suit- 
able alone  for  adult  life,  as  it  contains  relatively  more 
fat  and  sugar  than  necessary  proteids.  Boiling  tke  milk 
coagulates  the  albumin,  making  it  insoluble  and  difficult  of 
digestion.  Cow's  milk  is  richer  in  proteids  and  poorer  in 
sugar  than  human  milk ;  its  curd  is  more  dense  and  much 
more  difficult  of  digestion.  It  is  much  influenced  by  the 
food  given  to  the  cattle;  carrots,  turnips  and  parsnips 
changing  not  only  the  odor,  but  the  color  and  flavor  also. 
Fragrant  grasses  modify  the  taste  of  milk  and  butter. 
This  is  seen  in  the  superiority  of  June  butter.  Milk  is 
frequently  the  means  of  communicating  infectious  dis- 
eases, such  as  scarlet  fever  and  measles.  Steaming  the 
milk  by  raising  the  temperature  to  scalding,  but  not  to 


THEKAPEUTICS.  293 

the  boiling-point,  is  useful  in  destroying  impurities  which 
may  be  present,  and  thus  sterilizing  it. 

Beef  and  other  proteid  foods  increase  the  amount  and 
richness  of  human  milk ;  the  fats  present  in  the  milk  are 
not  obtained  from  fats  ingested,  but  from  a  splitting  up  of 
the  proteid  molecules.  A  pure,  fresh  meat  diet  gi-ves  milk 
containing  a  large  amount  of  fat ;  the  milk  sugar  and  ca- 
sein are  also  derived  in  the  same  way  from  the  proteid  food 
taken. 

Animal  Food. — Besides  the  muscle  substance,  all  beef 
contains  more  or  less  fat ;  the  red  color  is  due  to  the  hgemo- 
globin  present  in  the  meat  substance;  the  salts  are  potash 
and  phosphoric-acid  compounds.  Magnesium  phosphate 
and  calcium  phosphate  are  also  present  in  smaller  amount. 
The  amount  of  fat  present  varies  according  to  the  con- 
dition of  the  animal,  and  is  given  differently  by  different 
authorities.  In  the  substance  of  the  meat  itself,  after  the  re- 
moval of  visible  fat,  there  is  said  to  be  about  eleven  per  cent, 
in  the  ox,  and  three  per  cent,  in  the  sheep  and  in  the  fowl, 
about  two  per  cent,  of  fat  still  remaining.  Beef  contains 
four  times  the  amount  of  proteids  as  milk.  In  Great  Britain 
and  America  beef  leads  all  other  meats  as  a  staple.  Roast 
beef  is  the  form  it  takes  in  England,  while  in  the  United 
States  fried  steak  is  the  most  common  form  in  which  we 
find  it.  The  latter,  I  need  scarcely  say,  is  extremely 
indigestible.  Contrary  to  the  general  opinion,  rare  beef  is 
not  nearly  so  beneficial  as  that  which  has  been  properly 
cooked.  Cooking  is  really  a  partial  digestion,  as  it  softens 
the  fibre  and  makes  it  easy  of  maceration  in  the  stomach. 
Warm  foods  of  all  kinds  are  more  digestible  than  cold 
ones,  and  this  is  a  fact  to  be  remembered  when  the  diges- 
tion is  weak.  Steaks  should  be  broiled  by  a  quick  yet 
gentle  heat;  all  beef  should  be  thoroughly  masticated,  and 


294  FUN^CTIOlSrAL    NERVOUS    DISORDERS. 

not  eaten  in  too  large  amount  at  any  one  time.  Improper 
mastication  may  result  from  defective  teeth,  but  more 
often  the  pernicious  habit  of  bolting  food  is  the  cause  of 
the  weakened  digestion.  An  occasional  glance  at  some 
work  upon  table  etiquette  may  assist  in  overcoming  this 
habit.  Roast  beef  is  very  wholesome;  the  outer  or  first 
cut  is  less  digestible  than  the  inner  slices.  Mutton  is 
digestible,  but  not  so  nourishing  as  beef,  and  is  very  whole- 
some when  roasted.  Boiled,  with  caper  sauce,  and  served 
with  fresh,  well-cooked  vegetables,  it  is  digested  by  very 
weak  stomachs,  and  is  nourishing. 

The  preparation  of  meat  is  the  essential  thing  to  be  con- 
sidered ;  in  roasting  it  must  not  be  burned,  and  in  boiling 
it  should  not  be  cooked  to  pieces.  All  boiled  meats  should 
be  allowed  to  stand  in  their  own  liquor  for  some  time  after 
the  boiling  has  ceased,  to  reabsorb  the  juices;  otherwise 
they  will  be  dry.  Veal  is  not  often  digestible,  although 
often  tender.  It  must  be  carefully  cooked.  Pork  should 
be  selected  with  great  care;  it  must  not  be  dark  nor  very 
red,  but  of  a  delicate  pink  color,  with  very  white  fat. 
Salted  meats  should  be  only  mildly  salted  and  not  old,  as 
the  process  of  salting  toughens  them.  Simmer  the  meat 
gently,  as  furious  boiling  is  not  of  advantage.  In  spite  of 
the  reputation  which  bread  has  obtained  as  the  staff  of 
life,  meat  is  certainly  more  nutritious  and  strengthening. 

Vegetable  Foods. — The  cereals  are  the  most  important 
of  the  vegetable  foods ;  they  contain  not  only  starch,  pro- 
teids,  and  salts,  but  about  fifteen  to  twenty  per  cent,  of 
water.  The  nitrogenous  element  is  most  abundant  on  the 
exterior  of  the  grain,  but  coarse  foods,  containing  much 
bran,  are  indigestible.  The  finely  ground  flours  or  meals 
are  the  preparations  most  suitable  to  digestion;  some  of 
the  cellulose  or  external  envelope,  however,  may  be  di- 


THEKAPEUTICS.  295 

gested.  The  more  fat  a  vegetable  food  contains,  the  more 
difficult  is  it  of  digestion.  Vegetable  proteids  are  useful, 
but  they  are  not  so  easily  digested  and  elaborated  as  the 
animal  proteids.  There  is  also  more  waste  from  vegetable 
than  from  animal  food.  The  farinaceous  substances  are 
largely  composed  of  starch,  while  the  leguminous  seeds, 
such  as  peas,  beans,  and  lentils,  contain  much  proteid 
matter,  and  are  largely  used  in  the  form  of  soup  by  the 
poorer  classes. 

Potatoes  contain  principally  water  and  starch,  about 
two  per  cent  of  soluble  albumin,  a  small  amount  of  pot- 
ash and  of  chloride  of  sodium.  There  are  also  present  in 
the  cellular  tissue  phosphoric,  malic,  and  hydrochloric 
acids.  Green  vegetables  and  fruits  are  chiefly  of  value 
for  the  salts  they  contain;  they  are  therefore  of  use  in 
scurvy  and  allied  conditions.  They  fill  an  important 
place  in  the  treatment  of  functional  diseases  in  women. 

Food  Accessories. — Alcohol,  taken  regularly  in  large 
doses,  has  a  profound  effect  upon  the  nervous  system, 
affecting  all  the  mental  and  bodily  faculties;  by  its  direct 
action  upon  the  digestive  organs  it  causes  catarrh  and 
inflammation.  Up  to  a  certain  extent,  the  alcohol  taken 
into  the  system  is  readily  oxidized.  It  often  acts  as  a 
substitute  for  food  which  may  be  insufficient  in  amount, 
but  it  interferes  markedly  with  oxidization.  Small  doses 
excite  and  large  doses  paralyze  the  nervous  system.  Its 
stimulating  action  is  always  followed  by  a  corresponding 
depression.  In  small  doses  it  gives  a  feeling  of  warmth, 
but  even  moderate  doses  lower  the  temperature  of  the 
body.  Brandy  more  than  whiskey  hampers  salivary  diges- 
tion, although  some  claim  that  it  promotes  it  by  causing 
an  increased  flow  of  saliva.  All  wines  have  a  strong  re- 
tarding effect  upon  salivary  digestion ;  claret,  sherry,  port, 


296  rr]srcTio]S"AL  k'eryous  disordees. 

and  hock  even  in  so  small  a  proportion  as  one  per  cent 
have  a  marked  inhibitory  effect.  This  is  probably  due  to 
the  acidity  of  these  wines.  Digestion  is  interfered  v^itb 
by  malt  liquors,  according  to  their  acidity.  We  have 
spoken  before  of  water,  and  would  merel}^  observe  in  this 
])lace  that  although,  as  above  demonstrated,  wines  have 
an  inhibitory  effect  upon  salivary  digestion,  this  can  be 
materially'  lessened  by  the  addition  of  water  containing 
the  alkaline  carbonates. 

Alcoholic  beverages  should  be  given  with  the  greatest 
reserve  to  neurasthenics  or  nervous  persons.  As  a  rule,  it 
is  better  not  to  prescribe  them  at  all,  unless  in  combination 
with  the  bitter  tonics. 

Tea  exercises  a  most  decidedly  inhibitory  effect  upon 
salivary  digestion,  undoubtedly  on  account  of  the  tannin 
contained  in  it ;  when  used  at  all  by  persons  whose  diges- 
tive powers  are  in  any  way  impaired,  it  should  be  made 
extremely  weak  and  be  partaken  of  sparingly.  About  five 
grains  of  the  bicarbonate  of  soda  in  the  teapot  will  remove 
the  restraining  action  which  it  has  upon  the  salivary 
digestion. 

Coffee,  in  this  respect,  is  far  less  harmful  than  tea,  and 
the  same  may  be  said  of  cacao.  The  latter  is  popularly 
supposed  to  favor  digestion  much  more  than  tea  or  coffee, 
probably  because  it  is  used  in  a  much  weaker  state  than 
either  of  the  other  beverages;  it  is  commonh'  used  in  about 
a  two-per-cent  infusion,  whereas  tea  and  coffee  are  used  in 
about  a  five  and  seven  per  cent  infusion  respectively. 

Sugar  and  common  salt,  although  exercising  a  very 
considerable  influence  upon  peptic  digestion,  seem  neither 
to  favor  nor  to  retard  the  salivary  digestion.  Salt,  being 
to  a  certain  degree  a  condiment,  excites  the  secretion  of 
the  saliva.     Sugar  is  very  fermentable. 


THERAPEUTICS.  297 

Gastric  digestion  being  of  greater  extent  than  salivary, 
it  is  important  to  note  the  effect  upon  it  of  many  food 
accessories.  The  effect  of  ardent  spirits,  such  as  brandy, 
whiskey,  and  gin,  depends  upon  the  amount  of  alcohol  they 
contain ;  the  greater  the  amount  the  more  do  they  embarrass 
digestion.  In  the  proj)ortions  commonly  used  at  meals 
they  have  no  appreciable  action  of  the  kind,  neither  are 
they  in  any  way  beneficial.  If  they  be  taken  at  all,  they 
should  invariably  be  diluted  and  drunk  in  small  amount, 
as  large  amounts  markedly  impede  digestion. 

Wines  and  beers  have  a  much  more  inhibitory  influence 
upon  gastric  digestion.  Very  small  quantities  of  cham- 
pagne have  a  slightly  accelerating  effect,  due  probably  to 
the  stimulation  of  its  effervescent  qualities,  while  claret, 
sherry,  and  port,  more  especially  sherry,  have  a  markedl}'' 
retarding  action.  The  same  may  be  said  of  malt  liquors. 
When  taken  in  large  quantities,  they  very  decidedl}'^  re- 
tard the  digestion  of  bread  and  other  starchy  articles  of 
food.  Tea,  coffee,  and  cacao  in  strong  infusions  have  a 
powerful  retarding  influence  on  gastric  digestion,  but  when 
taken  in  weak  infusions,  as  cacao  is  usually  made,  the 
effect  is  slight.  The  retardation  is  especially  noticed  with 
starchy  foods.  Table  or  small  beer,  as  used  in  England,  or 
very  light  lager  beer,  such  as  the  two-per-cent.  beer,  taken 
while  in  its  effervescent  state,  has  probably  no  deferent 
effect  on  gastric  digestion,  or  none  worth  mentioning. 

The  influence  of  these  food  accessories  upon  pancreatic 
digestion  is  much  less  marked  than  upon  the  gastric  or 
the  peptic. 

Medicinal  Treatment. 

Reconstructive  Remedies. — Many  drugs  are  employed 
with  good  results  in  the  treatment  of  nervous  disorders. 


298  FUXCTIOKAL   >^"ERVOUS   DISORDERS. 

Coffee,  and  its  alkaloid  caffeine,  are  especially  useful  as  a 
domestic  remedy  for  slight  migrainous  headaches  which 
come  on  after  meals,  and  is  a  common  and  extremely  valu- 
able remedy  for  functional  headaches.  Cafe  noir  is  sup- 
posed to  be  eflScacious  in  hastening  digestion,  but  in  many 
nervous  dyspeptic  persons  its  use  is  detrimental.  In  ner- 
vous asthma  coffee  and  caffein  are  often  very  useful  when 
administered  in  strong  doses.  The  reflex  vomiting  of 
pregnancy  is  often  checked  by  the  use  of  alcoholic  drinks, 
as  whiskey  or  brandy,  and  these  stimulants  in  small  doses 
will  sometimes  be  found  useful  in  the  class  of  cases  under 
consideration  in  this  work.  Generous  wines  in  small 
quantities  act  as  a  reparative  food,  and,  as  they  restrain^ 
the  waste  of  nervous  tissue,  they  will  be  found  most  use- 
ful agents.  They  are  to  be  used  only  where  unmistak- 
ably indicated,  as  there  is  always  some  danger  of  inducing 
the  alcoholic  habit.  They  by  no  means  take  the  place  of 
the  natural  food  of  the  body,  although  their  use,  it  is  sup- 
posed, may  sometimes  tide  the  patient  over  a  critical 
period. 

Among  the  best  tonics  for  neurotic  individuals  are  the 
cinchona  preparations,  more  especially  in  those  cases 
which  have  a  malarial  element,  characterized  by  a  perio- 
dicity or  intermitteDC}"  of  the  symptoms.  As  bitter  tonics 
and  appetizers  they  are  of  advantage  to  stimulate  the 
digestive  powers,  thus  assisting  nutrition  and  strengthen- 
ing the  entire  system.  One  of  the  best  of  these  prepara- 
tions is  the  sulphate  of  quinine ;  in  small  doses  it  acts  as 
a  good  heart  stimulant,  and  is  preferable  to  digitalis  in 
cardiac  disorders.  In  large  sedative  doses  it  is  dangerous 
in  this  class  of  cases.  In  certain  reflex  nervous  asthmas, 
reflex  coughs  and  dyspnoeas,  however,  large  doses  may  be 
administered  with  advantage.     The  cinchona  preparations 


TIIEUAPEUTICS.  299 

(more  especially  the  sulphate  of  quinine)  act  most  bene- 
ficially and  quickly  in  neuralgias  of  malarial  origin.  It 
will  be  found  advantageous  to  combine  the  quinine  with 
opiates  if  the  pain  be  very  persistent  and  severe.  Mi- 
graine is  benefited  in  most  cases  by  a  combination  of 
quinine  and  digitalis. 

In  functional  and  catarrhal  affections  of  the  stomach 
and  intestines,  an  infusion  of  calumba  is  very  useful  in 
restoring  the  digestion  to  its  normal  condition.  A  bitter 
tonic,  disagreeable  to  take,  but  sometimes  of  value,  is 
quassia;  it  often  very  quickly  relieves  vertigo  of  stomachic 
origin.  Another  extremely  bitter  tonic  is  gentian;  it  is 
often  valuable  in  stimulating  the  digestion  in  functional 
nervous  disorders,  and  usually  succeeds  in  removing  the 
debility  which  is  at  the  root  of  these  ailments.  The  com- 
pound tincture  of  gentian  is  an  excellent  product,  and  can 
be  combined  with  the  cinchona  preparations,  which  are 
the  best  of  all  this  class.  These  should  be  taken  in  small 
quantities  and  at  regular  intervals;  they  all  increase  the 
force  of  assimilation  and  thus  act  as  strong  nerve  tonics. 

Condurango,  which  has  been  in  bad  odor  from  its  hav- 
ing been  recommended  as  a  specific  for  cancer,  is  said  to 
be  a  good  stomachic  and  appetizer.  I  have  seen  admi- 
rable results  from  its  use,  in  increasing  the  appetite  and 
the  digestive  powers,  when  its  fluid  extract  has  been  com- 
bined with  the  tincture  of  nux  vomica.  However,  Lauder 
Brunton  claims  that  it  is  physiologicall}^  inert  {Journal 
of  Anatomy  and  Physiology,  AjDril,  1876). 

Arsenic  in  the  form  of  Fowler's  solution  is  a  good  tonic 
to  the  nervous  system ;  through  its  beneficial  action  on  the 
digestive  function  it  gives  tone  and  strength  to  all  the 
organs,  thus  increasing  the  vital  resistance.  It  should  be 
used  with  great  caution,  in  view  of  its  poisonous  properties. 


300  FUNCTIONAL   NERVOUS    DISORDEES. 

Where  there  is  no  inflammation  of  the  digestive  organs, 
a  good  bitter  tonic,  with  the  addition  of  a  little  capsicum, 
is  all  that  will  be  required  in  the  way  of  medicine,  but  a 
generous  supply  of  nutritious  food  should  be  given.  When 
severe  nasal  or  gastric  catarrh  is  present,  this  must  be  first 
removed  before  any  efforts  are  made  toward  the  enrich- 
ment of  the  blood.  Astringent  tonics,  hot  water,  substan- 
tial meat  foods,  so  prepared  as  to  be  easy  of  digestion,  are 
here  indicated.  City  life  in  large  centres  is  incompatible 
with  the  best  hygienic  conditions;  a  few  weeks  in  the 
country  or  at  the  seaside  speedily  bring  a  restoration  of 
the  vital  forces  in  these  disorders.  Inhabitants  of  large 
and  busy  cities,  who  live  constantly  at  high  pressure,  re- 
quire a  more  sustaining  diet  than  the  residents  of  small 
towns  or  those  who  live  in  the  country.  City  life  tends 
directly  to  the  development  of  the  neuroses  by  its  enervat- 
ing action  upon  the  system. 

Generous  wines,  with  quinia,  are  highly  recommended, 
but  a  scientific  dietary  and  the  maintenance  of  proper 
hygienic  conditions  are  more  important  elements  in  the 
treatment. 

In  melancholia  and  the  psychoses,  tonics  are  especially 
indicated.  Wines  and  cordials ;  pure  air  and  pure  water ; 
proteid  and  carbohydrate  food  in  proper  proportions,  along 
with  drugs  which  stimulate  digestion;  and  mental  as  well 
as  physical  rest,  will  do  much  toward  reanimating  and 
restoring  these  patients. 

In  cases  in  which  chlorosis  is  present  we  find  the  follow- 
ing train  of  symptoms :  Marked  exaltation  or  depression 
of  spirits;  emaciation,  at  times  slight,  at  others  well  de- 
fined ;  paleness,  often  with  a  greenish  tinge  of  the  skin  and 
mucous  membranes;  pearly  appearance  of  the  sclerotic; 
puffiness,  most  marked  in  the  face;    development  of  ca- 


THEKAPEUTICS.  301 

chexia;  coldness  of  hands  and  lower  extremities;  full,  soft 
and  accelerated  pulse;  elevation  of  temperature;  thirst; 
dryness  of  cuticle ;  hysteria,  melancholia ;  muscular  debil- 
ity and  a  condition  of  general  nervousness;  irregular 
respirations;  irregular  neuralgic  pains;  spinal  sensitive- 
ness; palpitations;  a  dry,  barking  cough;  dyspepsia,  pyro- 
sis, a  depraved  appetite.  Vomiting  may  be  present  and 
constipation  is  a  frequent  accompaniment,  although,  after 
the  disease  has  existed  for  a  considerable  time,  diarrhoea 
may  be  present.  Irregular  and  excessive  flushing  of  the 
face,  an  ansemic  bruit  at  the  base  of  the  heart,  and  a 
venous  hum  in  the  neck  may  also  be  observed.  In  these 
cases  the  menstrual  function  is  always  affected,  and  may 
be  entirely  absent ;  on  the  other  hand,  menorrhagia  may 
exist.  Menstruation  may  be  painful,  irregular,  scanty,  or 
of  abnormal  color ;  leucorrhoea  is  very  often  present. 

The  above  is  a  brief  resume  of  the  symptoms  of  chloro- 
sis, a  condition  which  is  very  frequently  present  in  the 
class  of  diseases  under  consideration.  The  administra- 
tion of  the  various  preparations  of  iron  will  usually  give 
great  relief.  In  many  cases  of  chlorosis  the  disease  is  not 
recognized  by  the  physician,  because,  as  is  often  the  case, 
the  disturbances  of  menstruation,  the  dyspeptic  symp- 
toms, and  the  nervous  manifestations  appear  either  sepa- 
rately or  together  before  the  peculiar  pallid  appearance  of 
the  skin  has  reached  the  point  which  proclaims  the  disease 
even  to  an  inexperienced  eye.  In  the  treatment  of  chloro- 
sis, iron,  arsenic,  and  strychnine  are  invaluable,  and  may 
be  given  according  to  the  following  prescription : 


I^  Strych.  sulph.,  .         .         .        .         .  gr.  ^. 

Acid,  arsenics., gr.  -g^. 

Ferri  reduct., gr.  i. 

M. 


302  FU2S-CTI0XAL   K"EKVOUS    DISORDERS. 

This  in  tablet  form  is  an  excellent  preparation  for 
chlorotic  girls  and  neurasthenic  patients  generally. 

Iron  should  be  administered  at  meals,  as  these  are  the 
periods  when  the  gastric  fluid  contains  the  greatest  amount 
of  acid.  In  cases  in  which  pyrosis  or  "  water  brash"  is 
present,  the  iron  should  be  administered  between  meals. 
When  one  preparation  of  iron  has  been  used  without  ob- 
taining a  satisfactory  result,  another  should  be  tried.  The 
treatment  should  be  continued  without  intermission  dur- 
ing the  menstrual  periods,  and  should  not  be  discontinued 
until  the  disappearance  of  the  chlorosis ;  then  there  should 
be  an  intermission  for  about  a  month,  when  the  treatment 
should  be  again  taken  up  for  three  or  four  weeks.  The 
following  is  a  good  combination : 

I^  Mass.  Blaud, gr.  v. 

Hydrarg.  bichlor. ,         .         .         ,         .  gr.  /^y. 

Sti-ych.  sulph., gr-  sV- 

Acid,  arsenics., gr.  -^. 

M. 

One  of  these  tablets  should  be  taken  after  each  meal. 
As  a  recurrence  of  the  chlorosis  is  always  possible,  the  iron 
treatment  should  be  continued  for  some  time,  gradually 
increasing  the  intervals  between  the  administrations  and 
gradually  decreasing  the  periods  during  which  the  iron  is 
exhibited.  In  the  treatment  of  nervous  symptoms,  due 
consideration  must  be  given  to  the  patient's  constitution 
and  temperament.  In  full-blooded  and  vigorous  women, 
when  anything  approaching  hysterical  convulsions  pre- 
sents itself,  the  administration  of  iron  is  likely  to  be  pro- 
ductive of  more  harm  than  good ;  while  in  other  patients 
who  are  debilitated  from  loss  of  blood  or  other  cause  the 
nervous  symptoms  will  very  generally  disappear  with 
rapidity  under  the  treatment  by  ferruginous  preparations. 


THERAPEUTICS.  303 

In  neuralgia,  which  is  a  very  common  symptom  in  chlo- 
rotic  patients,  and  which  in  such  cases  changes  its  seat 
with  remarkable  rapidity,  iron  will  usually  prove  of  great 
benefit.  This  type  of  neuralgia  is  often  very  difficult  to 
recognize.  In  cases  of  facial  neuralgia,  local  applications 
should  be  combined  with  the  internal  administration  of 
iron,  and  may  consist  of  belladonna  or  chloroform ;  some- 
times hypoderinic  injections  of  morphine  may  be  given. 
In  functional  nervous  disorders,  while  placing  a  due 
amount  of  reliance  upon  drugs,  other  agents  must  not  be 
overlooked.  The  importance  of  a  proper  diet,  strictly 
adhered  to,  cold  or  tepid  baths,  and  a  suitable  form  and 
amount  of  bodily  exercise  cannot  be  overestimated.  With 
regard  to  bodily  exercise,  we  may  remark  that  while  in 
some  cases  it  is  a  valuable  adjunct  to  the  treatment,  in 
others,  in  which  neither  iron  nor  any  other  medicinal 
agent  will  be  of  advantage,  properly  directed  systematic 
exercises  alone  will  effect  a  cure. 

Antispasmodic  Ageiits. — Among  the  antispasmodic 
agents  which  are  useful  in  the  treatment  of  the  nervous  dis- 
orders of  women,  valerian  occupies  a  very  prominent  posi- 
tion. In  simulated  disease  in  hysterical  subjects,  its  value  in 
large  doses  can  scarcely  be  exaggerated.  In  cases  in  which 
vertigo  is  present,  its  administration  is  always  indicated. 

Asafoetida  may  be  prescribed  in  all  cases  in  which  vale- 
rian is  suitable,  but  it  possesses  the  disadvantages  of  an  ex- 
ceedingly disagreeable  odor  and  taste  and  a  liability  to 
cause  purging,  which  make  it  a  less  desirable  agent  than 
valerian.  In  violent  hysteria,  and  when  constipation  and 
hysterical  colic  exist,  asafoetida  has  been  found  to  be  use- 
ful. It  will  give  better  results  than  valerian  in  nervous 
disorders  of  the  digestive  and  respiratory  tract. 

Camphor  has  been  extensively  used  in  almost  all  neu- 


304  FUXCTIOXAL    NERVOUS    DISORDEES. 

rotic  disorders.  It  is,  however,  more  useful  in  the  nervous 
symptoms  accompanying  fevers  than  in  true  neuroses.  It 
has  been  highly  extolled  in  the  treatment  of  mania.  Its 
greatest  value  is  perhaps  as  an  anaphrodisiac. 

Ether  is  both  a  stimulant  and  an  antispasmodic,  but  its 
effect  is  transient.  A  few  drops  administered  when  pre- 
monitions of  an  hysterical  fit  are  noticed,  will  usually 
abort  the  attack.  In  spasmodic  and  nervous  affections 
unaccompanied  by  inflammation,  it  is  very  valuable.  In 
spasmodic  colic,  nervous  palpitations  and  headache,  and 
during  the  paroxysms  of  spasmodic  asthma,  it  will  be 
found  very  useful,  as  it  will,  in  fact,  for  many  nervous 
symptoms  arising  in  the  course  of  almost  any  disease. 
Hoffman's  anodyne  is  a  good  form  in  which  to  adminis- 
ter ether.  For  mental  emotion  or  hysteria  this  gives 
prompt  relief.  It  is  of  great  temporary  value  in  angina 
pectoris  and  in  spasmodic  asthma,  but  full  doses  must  be 
given  to  produce  the  desired  effect.  In  hysterical  sick- 
headaches  half -drachm  doses  should  be  given,  or,  combined 
with  the  ammoniated  tincture  of  valerian,  two-drachm 
doses  every  twenty  or  thirty  minutes.  All  abdominal 
irritations,  such  as  colic  or  diarrhoea,  causing  spasmodic 
contractions  of  the  arteries  of  the  lower  extremities,  which 
especially  in  children  are  often  accompanied  by  a  rush  of 
blood  to  the  head,  are  relieved  by  a  few  drops  of  Hoff- 
man's anodyne.  When  there  is  a  deficient  supply  of 
blood  to  the  lower  extremities,  spasm  of  the  muscles,  as  in- 
dicated by  painful  cramps  and  flexion  of  the  toes  upon  the 
soles  of  the  feet,  shows  reflex  irritation.  Hysterical  women 
are  often  victims  of  rumbling  and  gurgling  in  the  bowels, 
and  suffer  from  excessively  cold  feet,  the  result  of  arterial 
spasm  from  abdominal  irritation.  Two  teaspoonfuls  of 
Hoffman's  anodyne  is  an  efficient  remedy. 


THEEAPEUTICS.  305 

Oxide  of  zinc  has  been  used  in  almost  all  neurotic  affec- 
tions, and  some  authorities  claim  to  have  seen  great  benefit 
accrue  from  its  use,  especially  in  epilepsy.  Taking  all  the 
evidence  for  and  against  it,  however,  its  value  is  very 
questionable.  The  same  remarks  apply  to  the  acetate  and 
lactate  of  zinc. 

The  oxalate  and  nitrate  of  cerium  have  been  used  in 
neuroses  by  Sir  James  Simpson,  who  affirmed  that  be  had 
a  great  measure  of  success  with  them,  especially  in  the 
vomiting  of  pregnancy. 

Reflex  vomiting  of  cerebral  origin,  the  vomiting  of 
pregnancy,  and  seasickness  are  benefited  by  treatment 
with  the  bromides.  In  seasickness  the  dose  used  need  not 
be  large,  but  it  should  be  accompanied  by  a  goblet  or  two 
of  very  hot  water.  Used  in  this  way  they  are  very  suc- 
cessful agents,  but  the  hot  water  is  the  more  important. 
Palpitation  of  the  heart  is  benefited  by  them  when  not  de- 
pendent upon  aneemia  or  gastric  catarrh ;  but  when  due  to 
either  of  these  two  conditions,  rectification  of  the  gastric 
disorders  and  the  consequent  enrichment  of  the  blood  are 
of  primary  importance.  In  insomnia,  the  hypnotic  action 
of  the  bromides  is  well  marked.  They  are  often  prescribed 
with  benefit  in  alcoholic  delirium,  but  the  elimination  of 
the  poison  by  drinking  hot  water  and  the  assimilation  of 
nutritious  food  are  of  vastly  more  importance  in  the  treat- 
ment. Where  there  is  much  ansemia  the  bromides  are 
harmful,  as  they  are  especially  liable  to  set  up  gastric 
catarrh  if  not  properly  administered.  In  melancholia  and 
hypochondriasis  they  may  sometimes  be  used  with  benefit, 
while  again,  in  the  same  conditions,  their  exhibition  may 
be  harmful.  Migraine  of  the  congestive  type  is  often 
markedly  benefited  by  the  use  of  the  bromides,  especially 

of  the  effervescent  preparations.     In  the  vascular  neuroses 
20 


306  FUXCTIOXAL    XEKTOUS    DISORDEKS. 

they  often  give  marked  relief;  in  morbid  blushings  and 
flushings  occurring  at  the  menopause,  or  whenever  the 
local  circulation  is  disturbed,  the  bromides  are  indicated. 
In  the  respirator}^  neuroses,  reflex  coughs  of  abdominal  or 
pelvic  origin,  false  croup,  and  reflex  asthma,  full  doses 
usually  give  prompt  relief.  In  ovarian  neuralgia,  and 
irritation,  accompanied  by  menorrhagia  or  other  functional 
disorder  of  the  uterus,  the  exhibition  of  the  bromides  fre- 
quently removes  these  distressing  conditions. 

Narcotics. — Opiates  have  been  much  used  in  the  class 
of  diseases  under  consideration,  for  the  purpose  of  allaying 
spasm,  relieving  pain,  and  counteracting  the  insomnia 
which  is  often  present.  The}^  appear  to  be  of  most  use  in 
cases  of  insanity,  ecstasj%  melancholia,  and  religious  mania, 
but  their  unpleasant  after-effects  and  the  disagreeable 
dreams  produced  by  their  use,  together  with  the  danger  of 
causing  the  opium  habit,  are  facts  which  must  receive  due 
consideration  from  the  phj'sician  and  make  him  cautious 
in  prescribing  these  agents. 

In  hysteria,  opium  combined  with  an  antispasmodic, 
such  as  valerian  or  asafoetida,  is  often  most  valuable. 
When  great  pain  is  present,  such  patients  are  very  toler- 
ant of  opium,  and  a  larger  dose  than  the  usual  one  must 
be  administered.  The  local  application  of  opiate  lotions 
is  also  helpful,  and  should  not  be  neglected. 

Sometimes  in  chorea,  moderateh"  large  doses  of  opium 
are  productive  of  very  great  benefit. 

In  neuralgias  it  was  formerly  the  custom  to  use  opium 
internally  and  to  apply  it  externally  to  the  affected  part, 
but  since  hypodermic  injections  of  morphine  have  come 
into  general  use,  they  h-ave  quite  superseded  the  other 
forms  of  treatment.  When  the  neuralgia  is  facial  the 
application  of  a  strong  solution  of  sulphate  of  morphine  to 


THERAPEUTICS.  307 

the  gums  and  buccal  surfaces  of  the  cheek  on  the  affected 
side  will  often  prove  most  efficient.  In  these  cases  qui- 
nine should  alwaj^s  be  administered  internally,  as  it  will 
in  great  measure  assist  to  retard  the  return  of  the  neural- 
gia. In  tic  doloureux,  which  is  an  extremely  obstinate 
affection,  large  doses  of  opium  have  always  given  more  re- 
lief than  any  other  method  of  treatment. 

In  neuralgia,  especially  of  the  facial  type,  the  internal 
administration  of  belladonna  has  been  most  favorably 
spoken  of.  It  should  be  given  in  frequently  repeated 
doses,  to  be  reduced  as  the  pain  becomes  less.  Its  use 
should  be  continued  until  all  traces  of  the  neuralgic  pain 
have  disappeared.  In  many  cases  it  will  be  expedient  to 
administer  fairly  large  doses  of  the  sulphate  of  quinine  to 
prevent  the  return  of  the  attack.  The  local  application  of 
belladonna  has  been  followed  by  very  satisfactory  results 
in  cases  in  which  the  affected  nerve  is  superficial.  In  se- 
vere cases  the  part  should  first  be  blistered,  and  the  bella- 
donna applied  after  the  removal  of  the  epidermis.  After 
the  disappearance  of  the  pain,  quinine  should  be  adminis- 
tered. In  the  nervous  colic  which  frequently  occurs  in 
hot  weather  and  in  tropical  climates,  belladonna  has 
proved  of  signal  service.  Some  practitioners  claim  that 
this  drug  has  given  gratifying  results  in  cases  of  insanity, 
but  other  authorities  assert  that  they  have  never  seen  any 
benefit  from  its  use;  wherefore  it  would  seem  that  its 
value  in  these  cases  is  not  fully  established.  Belladonna 
is  a  powerful  stimulant  and  tonic  to  the  sj^mpathetic  nerve 
centres,  especially  those  which  have  supervision  over  the 
involuntary  muscular  fibres.  It  is  of  the  greatest  value 
in  functional  disorders  of  such  organs  as  contain  these 
fibres,  as  for  instance  the  alimentary  canal  from  the  phar- 
ynx to  the  anus,  the  genito-urinary  passages,  the  heart, 


308  FUifCTIONAL   ifERVOUS   DISORDERS. 

and  the  whole  arterial  system.  In  nervous  women  with 
globus  hystericus  there  is  spasm  or  paralysis  of  the 
oesophagus.  This  is  usually  relieved  by  belladonna.  In 
hysterical  gastrodynia  it  is  sometimes  of  much  benefit. 
In  chronic  constipation  resulting  from  uterine  or  ovarian 
irritation,  it  alone  often  corrects  this  condition.  In  reflex 
asthma  one-fifteenth  of  a  grain  of  atropine,  injected  hypo- 
dermically  low  in  the  nape  of  the  neck,  often  affords 
prompt  relief.  The  constipation  of  nervous  women  and 
hypochondriacs  has  been  successfully  treated  by  small 
doses  of  belladonna,  which  will  often  effect  the  desired 
result  when  powerful  purgatives  have  failed.  In  these 
cases  the  best  period  for  its  administration  is  at  bedtime. 
It  may  be  added  that  abdominal  massage  properly  given 
is  in  these  cases  a  specific.  In  gastralgia  and  enteralgia 
belladonna  has  also  been  found  useful.  Where  there  is  a 
tendency  to  constipation  it  may  be  given  at  mealtimes  or 
at  bedtime. 

In  the  uterine  pains  of  neuralgic  character  occurring  in 
chlorotic  subjects,  belladonna  is  a  most  useful  agent.  It 
may  be  used  either  in  the  form  of  a  rectal  or  a  vaginal 
injection ;  if  the  former,  about  fifteen  minims  of  the  tinc- 
ture should  be  injected  with  a  little  water ;  if  the  latter,  a 
strong  decoction  should  be  employed,  say  about  one  ounce 
to  three  pints,  and  repeated  twice  or  thrice  daily.  In  the 
vomiting  of  pregnancy,  the  extract  of  belladonna,  made 
into  a  thin  paste  by  meaiis  of  water,  and  applied  with 
friction  over  the  hypogastric  region,  has  been  found  to  be 
remarkably  successful.  After  the  friction  a  compress  of 
wet  lint,  covered  with  gutta-percha  tissue,  or  oiled  silk, 
should  be  applied.  Belladonna  has  also  been  successfully 
used  for  the  same  purpose  in  the  form  of  applications  to 
the  cervix.     In  the  salivation  occurring  in  some  neurotic 


THEEAPEUTICS.  309 

patients,  small  doses  of  the  sulphate  of  atropine  have  been 
used  with  good  results.  In  spasmodic  asthma,  smoking 
the  dried  leaves  of  belladonna  has  given  relief,  often  when 
all  other  agents  have  failed.  If  the  patient  has  an  insur- 
mountable objection  to  smoking,  the  drug  may  be  adminis- 
tered internally,  but,  although  some  relief  may  be  obtained 
in  this  manner,  the  results  are  by  no  means  as  satisfactory 
as  those  produced  by  the  smoking. 

Dr.  William  M.  Leszynsky,  in  a  paper  upon  the  use  of 
atropine  in  the  treatment  of  localized  muscular  spasm,  read 
by  him  before  the  New  York  Neurological  Society  in  Feb- 
ruary, 1891,  says  (and  his  remarks  show  the  value  of  the 
drug  in  cases  in  which  the  spasm  is  of  functional  origin) : 

"In  March,  1884,  I  reported  a  case  of  clonic  torticollis 
successfully  treated  by  the  subcutaneous  administration  of 
the  sulphate  of  atropine.  The  following  is  a  brief  synopsis 
of  the  case:  Female,  21  years  of  age;  unmarried;  clonico- 
tonic  spasm  affecting  the  right  sterno-cleido-mastoid  mus- 
cle, of  nearly  two  months'  duration. 

"The  initial  dose  was  one-eightieth  of  a  grain,  which 
was  daily  increased  in  amount  until,  on  the  twentieth  day, 
she  was  receiving  nearly  one-sixth  of  a  grain  (the  maxi- 
mum dose),  which  was  continued  in  the  same  quantity 
daily  for  four  daj^s,  when  recovery  supervened. 

"  No  decided  improvement  was  manifested  until  the  in- 
jection of  nearly  one-sixth  of  a  grain.  All  other  treat- 
ment was  deemed  auxiliary  to  the  atropine.  In  the 
discussion  which  followed,  it  was  claimed  that,  as  a  num- 
ber of  other  remedies  (galvanism,  bromides)  were  used  in 
conjunction  with  the  atropine,  it  would  be  difficult  to 
determine  which  effected  the  cure.  From  the  close  obser- 
vation of  this  case,  I  felt  confident,  and  so  expressed  my- 
self at  the  time,  that  the  recovery  could  be  attributed  to 


310  PUJSrCTION'AL    XEEVOUS    DISORDERS. 

the  effect  of  the  atropine.  Subsequently  the  long-wished- 
for  opportunity  presented  itself,  which  enabled  me  to  test 
the  efficacj"  of  the  drug  in  a  similar  form  of  spasm,  un- 
trammelled by  the  objectionable  association  of  other  reme- 
dies. I  therefore  take  pleasure  in  submitting  the  history 
of  the  following  case  for  your  consideration  and  criticism : 

"Charles  C,  born  in  the  United  States,  37  years  of  age 
and  a  painter  by  occupation,  presented  himself  for  treat- 
ment June  2d,  1888.  Three  years  previous,  muscular 
spasm  began  on  the  right  side  of  the  neck,  arising  six 
weeks  after  an  abscess  had  been  opened  at  the  angle  of  the 
jaw  on  the  right  side.  The  force  of  the  spasm  is  increased 
by  mastication  and  closure  of  the  jaw,  and  it  is  more  active 
upon  mental  excitement.  He  is  frequently  aroused  from 
sleep  by  the  severity  of  the  paroxysm. 

"  There  is  no  complaint  of  pain,  but  only  of  numbness  in 
the  right  lower  lip.  His  occupation  frequently  biought 
him  in  contact  with  lead,  but  he  never  suffered  from  colic 
or  paralysis.  There  is  no  histor}^  indicative  of  trauma  or 
syphilitic  infection.  Formerly,  alcoholic  excesses.  The 
bowels  are  constipated,  but  his  appetite  is  good. 

"  He  was  treated  by  means  of  medicines  and  electricity 
for  four  months  without  relief. 

"  He  is  a  fairly  nourished  man  of  average  height.  There 
is  well-pronounced  clonico-tonic  spasm  affecting  the  right 
platysma,  forcibly  drawing  downward  the  fascia  about  the 
chin  and  the  lower  angle  of  t-he  mouth. 

"  The  clonic  character  of  the  spasm  preponderates,  and  is 
almost  constant.  The  muscle  is  hypertrophied  to  nearly 
four  times  its  normal  size,  and  its  outline  is  distinct  and 
well  defined.  There  is  an  area  of  complete  anaesthesia  one 
centimetre  and  a  haff  by  three  centimetres  at  the  vermilion 
border  of  the  lower  lip,  near  the  angle  of  the  mouth  on  the 
right  side,  which  extends  inward  over  the  mucous  mem- 
brane and  over  the  alveolar  process  in  the  lower  jaw. 

"  The  mechanical  irritability  of  the  facial  muscles  is  well 


THERAPEUTICS.  311 

marked.  The  jaw  jerk  is  demonstrable.  There  is  no 
apparent  caries  of  the  teeth.  There  is  no  abnormality  evi- 
dent in  other  portions  of  the  body. 

"  Treatment. — A  cantharides  plaster  was  placed  over  the 
affected  mnscle. 

"June  9th. — One  week  has  elapsed  since  treatment  was 
begun,  but  there  is  no  improvement  in  the  spasm.  The 
mechanical  irritability  of  the  facial  muscles  has  diminished. 
He  sleeps  better.  Injected  Yh>  ^^  ^  grain  of  sulphate  of 
atropine  into  the  platysma. 

"10th.— Gr.  y^o- 

"11th. — Sleeps  well,  and  the  spasm  is  less  frequent. 
(rr   ^~ 

"12th. — Vertigo  was  complained  of  half  an  hour  after 
the  injection.  He  says  he  is  very  much  better.  The  ex- 
aggerated mechanical  irritability  of  the  facial  muscles  has 
markedly  decreased.  There  is  also  some  abatement  in  the 
frequency  of  the  spasm,  which  was  formerly  produced  or 
aggravated  by  closing  the  jaw  or  turning  the  head  to  the 
left. 

"These  movements  can  now  be  accomplished  with  im- 
punity. Sensation  is  returning  in  the  ansesthestic  area. 
Only  one  slight  spasm  occurred  to-day.  The  tonic  char- 
acter of  the  spasm  has  entirely  subsided.     Gave  gr.  -^. 

"13th.— Gr.  sV- 

"14th. — Spasm  is  induced  by  pressure  over  the  alveolar 
process  in  the  right  inferior  maxilla,  in  the  locality  of  the 
second  bicuspid  tooth  (which  has  been  lost).     Atropine, 

"loth.— Gr.  eV 

"16th. — No  spasm  since  last  note.  Onlj''  slight  vertigo 
after  last  dose.     Gr.  ^^g-. 

"  19th. — Has  been  receiving  daily  injections  of  gr.  ^ 
without  producing  toxic  symptoms.     Injected  gr.  -^-^. 

"  21st. — He  did  not  call  yesterday.  No  spasm  since  last 
note.     Gr.  -^-^. 

"  23d.— No  attack.     Says  he  is  well.     Gr.  ^. 

"  26th. — No  injection  since  last  note.     Spasm  has  not  re- 


312  FUNCTIONAL   NEKVOUS    DISOEDEES. 

turned.  The  most  energetic  effort  fails  to  produce  any 
spasmodic  action  in  the  platysma.  Administration  of 
atropine  discontinued. 

"August  18th. — Reports  to-day  that  he  has  remained 
free  from  spasm, 

"  The  successful  treatment  in  this  case  extended  over  the 
brief  period  of  two  weeks,  and  was  restricted  to  the  daily 
administration  of  atropine. 

"  The  solution  used  was — 

i^  Atropinte  sulph., gr.  i. 

Aq.  destil. , |  i. 

M. 

"  One  minim  of  this  solution  represents  4^  of  a  grain  of 
atropine.  My  method  has  been  to  give  four  minims  (gr. 
y|^)  at  the  first  injection,  and  to  be  on  the  alert  for  consti- 
tutional effects.  Upon  discovering  that  there  is  no  idio- 
syncrasy in  regard  to  the  drug,  it  is  administered  once 
daily,  and  the  quantity  gradually  increased  from  day  to 
day  until  the  desired  effect  is  produced  or  intolerance  is 
established. 

"  The  production  of  severe  constitutional  symptoms  is  not 
an  essential  feature  in  this  plan  of  treatment. 

"One  of  the  experimental  physiological  efforts  of  the 
drug,  when  given  in  sufficient  quantity,  is  to  paralyze  the 
motor  nerves,  first  affecting  their  trunk. 

"  I  am  not  prepared  to  say  whether  the  atropine  relieves 
the  spasm  through  its  constitutional  action  and  its  ulti- 
mate paralytic  effect  upon  the  motor  nerve  trunk,  or  by 
its  immediate  local  action. 

"  It  seems  to  me,  however,  that,  bj^  injecting  the  fluid 
directly  into  the  substance  of  the  muscle,  it  is  not  so 
rapidly  absorbed,  and  thus  has  ample  opportunity  to  act 
locally  upon  the  intra-muscular  nerve  elements.     There  ap- 


THERAPEUTICS.  313 

pears  to  be  no  ground  for  the  assumption  that  the  atropine 
possesses  an  elective  affinity  for  the  hj^perkinetic  area  after 
its  absorption  into  the  general  circulation.  This  remedial 
measure  deserves  a  fair  trial  in  analogous  cases  before 
resorting  to  surgical  procedures,  such  as  nerve  stretching 
or  tenotomy,  the  results  of  which  are  not  always  encourag- 
ing. 

"  The  improvement  in  the  following  case  of  facial  spasm 
seems  worthy  of  note : 

"On  the  29th  of  May,  1888,  I  was  consulted  by  M.  M., 
a  widow,  50  years  of  age,  who  stated  that  for  nearly  a 
year  the  left  upper  eyelid  has  been  tremulous.  Facial 
spasm  developed  four  months  ago.  It  is  worse  in  wet 
weather  and  upon  mental  excitement.  The  cause  of  the 
spasm  is  unknown.  She  has  suffered  from  occasional  ver- 
tical cephalalgia  during  the  last  two  years.  Climacteric 
three  years  ago.  She  received  galvanic  treatment  for  six 
months  without  any  perceptible  change.  There  is  con- 
stant tremor  in  tlie  lower  segment  of  the  orbicularis  palpe- 
brarum, also  frequent  clonic  spasm  affecting  all  of  the 
left  facial  muscles.  There  are  no  teeth  in  the  left  upper  or 
lower  jaw.  They  were  lost  during  pregnancy.  No  ten- 
derness oyer  the  alveolar  processes.  No  spinal  tenderness. 
The  pupils  are  small,  but  react  normally  both  to  light  and 
in  accommodation.  Hypermetropia,  2  D.  No  fundus 
lesion. 

"  She  was  kept  under  observation  until  June  9th,  when 
she  received  the  first  injection  of  yiir  of  a  grain  of  atro- 
pine. The  needle  was  introduced  deeply  into  the  tissues 
of  the  face,  near  the  exit  of  the  facial  nerve  at  the  stylo- 
mastoid foramen. 

"June  10th. — The  spasm  is  a  little  more  frequent,  but 
weaker.     Gave  injection  of  five  minims. 

"11th. — Face  was  flushed  for  nearly  two  hours  after  the 
injection.     There  is  decided  improvement.     tT[v. 

"  1 2th. — Flushing  of  the  face  and  dryness  of  the  mouth 


314  FUNCTIONAL   NERVOUS    DISORDERS, 

and  throat  all  of  yesterda}^  afternoon.  She  says  she  is 
much  better,  and  the  improvement  is  evident.     TT[vi. 

"13th.— mvij. 

"14th. — Doing  well.      TUviij.  (gr.  e^). 

"15th.— mix. 

"  16th. — lUx.  Spasm  in  orbicularis  palpebrarum  is  quite 
noticeable,  but  feeble. 

"  19th. — Has  had  daily  injection  since  last  note.  Much 
improved.  The  only  symptoms  following  the  injection 
are  flushing  and  headache,  which  subside  in  a  few 
hours. 

"  Since  beginning  the  use  of  atropine  I  have  never  wit- 
nessed a  well-marked  facial  spasm.  The  orbicularis  pal- 
pebrarum is  mostly  affected,  but  not  so  much  as  formerly. 
Tremor  has  taken  the  place  of  the  spasm  in  the  other  mus- 
cles,    mxij.  (gr.  ^). 

"  23d. — Daily  injection  since  last  note. 

"  30th. — She  says  she  has  an  occasional  spasm,  as  before, 
but  neither  so  severe  nor  so  frequent.     tti,xv. 

"October  loth. — She  reports  to-day  having  discontinued 
treatment,  and  states  that  thus  far  the  improvement  has 
been  permanent. 

"It  is  well  known  that,  in  this  peculiar  and  obstinate 
affection  with  an  obscure  pathology,  remissions  occasion- 
ally occur  independently  of  treatment. 

"  The  improvement,  however,  in  this  case  was  sufficiently 
encouraging  to  commend  this  method  of  treatment  for 
further  trial." 

Stramonium,  which  is  very  similar  in  its  action  to  bella- 
donna, may  be  used  in  the  same  class  of  cases.  When 
one  fails,  the  other  should  always  be  tried,  as  many  cases 
may  be  relieved  by  the  one  and  not  at  all  benefited  by  the 
other. 

In  insanity  and  chorea,  and  especially  in  cases  of  mono- 
mania with  hallucinations,  stramonium  has  been  highly 


THERAPEUTICS.  315 

extolled,  but  it  is  in  spasmodic  asthma  that  its  value  is 
most  apparent.  The  powdered  leaves  should  be  smoked  in 
the  form  of  cigarettes,  or  in  a  pipe,  mixed  with  equal  parts 
of  dried  sage  leaves.  Inhalations  of  the  drug  are  used  but 
are  much  less  reliable.  In  neuralgias  the  internal  admin- 
istration of  the  tincture  of  stramonium  has  been  found  to 
be  of  great  service.  It  should  be  given  in  small  doses — 
four  or  five  minims  repeated  every  three  or  four  hours. 
Plasters  made  of  stramonium  have  also  been  used  in  the 
treatment  of  neuralgias,  especially  those  of  the  scalp,  and 
liave  many  advocates,  but  it  is  only  in  transient  and 
superficial  neuralgias  that  they  can  be  of  any  benefit. 

Hyoscyamus  is  a  very  valuable  drug,  with  properties 
similar  to  those  of  belladonna  and  stramonium.  It  is  most 
useful  as  a  sedative  in  nervous  disorders,  and  is  of  great 
value  when  given  internally  in  the  treatment  of  neural- 
gias. It  may  also  be  locally  applied  in  cases  in  which  the 
affection  is  transient  and  superficial. 

In  hysteria  its  use  has  greatly  benefited  the  patient, 
more  especially  when  convulsions  have  occurred. 

Cannabis  indica,  or  hashish,  is  a  drug  which  deserves 
to  be  employed  in  functional  diseases  more  often  than  is 
the  case.  It  may  be  given  when  there  is  no  acute  inflam- 
mation present.  In  migrainous  headaches  it  is  a  remedy 
of  great  value  and  also  in  neuralgia.  Its  principal  effect 
IS  to  ward  off  tbe  attack  rather  than  to  stop  it  when  pres- 
ent. I  have  a  very  favorable  opinion  of  it  as  a  preventive 
agent  under  these  conditions.  It  is  an  excellent  substitute 
for  opium,  causing  none  of  the  evil  effects  of  the  latter. 
In  treating  migrainous  headache  we  should  not  forget 
that  gastric  irritation  is  usually  the  cause  of  the  pain, 
and  that  relief  of  the  stomach  disorder  usually  causes 
a  disappearance  of  the  headache.     Cannabis  indica  is  of 


816 


FUNCTIONAL    NERVOUS    DISORDERS. 


value  in  some  cases  of  hysteria,  and  may  also  be  used 
sometimes  for  the  relief  of  dysmenorrhoea. 

The  following  combination  is  highly  recommended  by 
Dr.  Henry  J.  Kenyon  as  a  nerve  tonic  in  chronic  neural- 
gic headaches  and  other  neuralgias : 


I^  Zinc  phosphide, 

gr-  A 

Ext.  cannabis  ind., 

gr-  h 

Ext.  nux  vom., 

gr.  h 

Sodium  arseniate, 

gi--  6^ 

Quinine  sulph., 

•         gr.  h 

Ext.  aconite  root,  . 

gr-  ru 

One  tablet  should  be  taken  at  10  a.m.  and  at  4  and  9  p.m. 
and  the  number  increased  by  one  tablet  every  week  until 
four  are  taken  three  times  daily ;  they  should  be  taken 
steadily  for  three  or  four  months.  Thej''  act  as  an  altera- 
tive to  diseased  nerves. 

Lobelia  is  an  excellent  agent  in  nervous  asthma,  and 
frequently  gives  much  relief  to  patients  who  have  received 
no  benefit  from  the  administration  of  either  belladonna  or 
stramonium.  It  is  best  given  in  the  form  of  the  tincture, 
in  doses  of  from  ten  to  twenty-five  drops,  three  or  four 
times  a  day. 

Aconite  is  a  product  of  special  value  in  neuralgias  and 
nervous  headaches;  it  is  also  very  useful  in  amenorrhoea 
dependent  upon  the  existence  of  a  condition  of  spasm  in 
the  uterus.  Three  minims  of  the  tincture  should  be  given 
thrice  dail5\  The  following  combination  in  tablet  form 
has  been  found  useful  in  acute  attacks  of  tic  douloureux: 


I^  Aconite  amorph. , 

gr-  Tk- 

Antifebrin,    . 

gr.  ij. 

Quin.  mur.. 

gr.  i. 

Arsen.  chlorophos., 

gr.  tIo 

Strych.  mur., 

gr.  rh 

Almost  the   only  class  of  nervous  diseases  in  which 


THERAPEUTICS.  '617 

chloral  has  been  used  with  any  great  measure  of  success 
is  acute  mania.  In  this  condition  it  will  quiet  agitation 
and  induce  sleep.  In  melancholia  and  several  other  con- 
ditions its  action  is  so  depressing  as  to  contraindicate  its 
use.  In  asthma  and  in  insomnia  it  may  produce  temporary 
benefit.  Equal  parts  of  chloral  and  camphor  triturated 
together  form  a  clear  liquid,  which,  when  painted  over  the 
surface  at  the  seat  of  pain,  is  of  great  value  in  neuralgia. 

For  the  relief  of  nervous  headaches  the  following  for- 
mula has  been  found  excellent : 

I^  Acetanilid,   ......         gr.  iij. 

Caniph.  monobrom.,    ....         gr.  ij. 

Cafleincit. , gr.  i. 

This  is  best  used  in  tablet  form,  and  may  be  repeated 
every  two  hours  as  needed. 

When  much  flatulence  is  present  it  is  well  to  give 
as  an  antifermentative  two  grains  of  the  salicylate  of 
soda,  combined  with  charcoal,  ginger,  and  aromatics. 
This  is  useful  when  taken  in  tablet  form  an  hour  or  two 
after  meals,  with  a  plentiful  supply  of  water. 

Electko-Therapeutics. 

This  branch  of  medical  science  is  at  present  making 
such  forward  strides,  is  undergoing  such  rapid  changes, 
and  is  of  so  great  importance  in  the  treatment  of  the 
diseases  which  we  have  been  considering,  that  the  reader 
is  referred  to  special  works  upon  the  subject.  Few  agents 
are  more  useful  in  nervous  disorders  than  electricity, 
but  the  limitations  of  this  work  do  not  permit  of  the 
extensive  consideration  of  the  topic  which  it  deserves, 
while  to  treat  it  cursorily  might  be  misleading  and 
would  certainly  be  unsatisfactory. 


318  FU]SrCTIONAL   ifEKVOUS    DISORDERS. 


Dilatation  for  Stenosis  and   Flexion  of  the 
Uterus. 

In  many  neurasthenic  and  hysterical  women,  this  proce- 
dure may  be  necessary.  Frequently  nervous  disorders  are 
dependent  upon  chronic  endometritis,  obstructive  dysmen- 
orrhoea,  and  sterility,  and  to  remove  the  inflammation 
and  the  obstructions  to  menstruation  and  insemination,  it 
is  often  necessary  to  dilate  and  straighten  the  uterine 
canal.  The  stenosis  is  very  frequently  at  the  internal  os, 
and  is  caused  by  flexion  of  the  neck  on  the  body.  This 
condition  is  the  result  of  pelvic  inflammation,  subinvolu- 
tion, or  hypertroph}^,  v^hich  forces  down  the  uterus  and 
the  cervix  against  the  posterior  vaginal  wall,  thus  deflect- 
ing the  cervix  while  in  a  softened  condition  upward  on 
the  body,  or  flattening  the  end  of  it  to  a  button-shape.  It 
deforms  the  external  os,  causing  it  to  become  a  mere  slit. 

Schroeder  *  says :  "  Stenosis  of  the  cervix  may  be  con- 
genital or  acquired.  The  congenital  form  sometimes  in- 
volves the  whole  cervical  canal,  and  is  very  frequent  at 
the  external  os,  which  is  much  contracted ;  seldom  at  the 
internal  os.  In  the  normal  uterus  (with  the  small  cervix 
and  the  smaU  external  os  of  the  undeveloped  uterus  we  are 
not  concerned  at  present)  the  vaginal  portion  is'  sometimes 
very  long,  hard,  and  gristly,  and  projects  unusually  pointed 
and  conical  into  the  vagina.  On  the  point  is  the  external 
OS,  so  small  as  sometimes  scarcely  to  be  perceived,  and  in 
the  speculum  it  is  difficult  to  discover  the  small  opening, 
and  then  often  only  by  a  drop  of  mucus  protruding  from 
it.     Frequently  the  anterior  lip  projects  and  overlaps  the 

*  Karl  Schroeder :  "  Krankheiten  der  weiblichen  Geschlechtsor- 
gane,"  Berlin,  1881. 


THERAPEUTICS.  319 

posterior,  so  that  the  os  is  hidden  as  by  a  valve."  These 
are  conditions  of  defective  development.  In  the  majority' 
of  cases  of  stenosis  the  obstruction  is  at  the  internal  os, 
and  is  the  result  of  anteflexion.  On  passing  the  sound  in 
thcvse  cases,  it  meets  with  an  obstruction  which  is  quite 
sensitive,  due,  probably,  to  inflammatory  hypersesthesia  or 
irritability  from  flexion  compression  of  the  nerves  at  the 
angle.  This  obstruction  may  exist  and  there  may  still  be 
no  dysmenorrhoea.  The  internal  os  is  occluded  by  inflam- 
matory swelling  before  dysmenorrhoea  manifests  itself 
from  this  cause,  although  sterility  is  the  common  result. 

Duncan  *  recommends  as  very  successful  in  dysmenor- 
rhoea spasmodica  mechanical  treatment  by  dilatation  with 
bougies ;  the  point  he  insists  on  is  the  stretching  or  dis- 
tention of  the  internal  os,  using  in  some  cases  as  high  as 
No.  13  or  13,  corresponding  to  male  bougies,  but  with  a 
different  curve. 

Sir  James  Simpson,  of  Edinburgh,  maintained  that 
stenosis  of  the  internal  os  produces  dysmenorrhoea  and 
sterility,  and  devised  a  metrotome  for  cutting  the  constric- 
tion. 

There  is  no  doubt  that  flexions  are  a  very  great  cause  of 
sterility,  not  only  by  mechanical  obstruction,  but  also  by 
producing  secondarily  strongly  alkaline  uterine  and  cervi- 
cal catarrhs,  which  destroy  the  vitality  of  the  sperma- 
tozoa. 

Miiller  f  states  that  "  conception  may  be  rendered  difficult 
by  a  flexion  of  the  uterus.  This  pathological  condition  in 
the  majority  of  cases  implicates  the  narrowed  portion  of 

*  J.  Matthews  Duncan:  "Clinical  Lectures  on  the  Diseases  of 
Women, "  1882. 

f  P.  Miiller:  "Cyclopsedia  of  Obstetrics  and  Gyngecology,"  Vol. 
xi.,  pp.  SQetseq.,  1887,  article  "Sterility." 


320 


FUXCTIOXAL    XERYOCS   DISORDERS. 


the  uterine  body;  viz.,  where  normally  the  uterine  walls 
are  in  simple  apposition  they  become  firmly  compressed, 
thus  producing  a  stenosis  of  the  uterine  canal." 

The  sharper,  more  acute  the  angle  of  flexion,  the  more 
certain  the  sterilitj^;  and,  if  the  cervical  canal  is  plugged 
with  thick,  tenacious  mucus,  there  is  no  doubt  of  its  being 
an  absolute  cause  of  that  condition.  Flexions  of  the  uterus 
cause  many  reflex  symptoms — vertigo,  headache,  neuras- 
thenia, nausea  and  vomiting,  and  very  many  other  hys- 
tero-neuroses.     These  are  only  relieved  by  dilatation  and 


Fig.  27. 


Fig.  28. 


proper  intra-uterine  and  extra-uterine  treatment.  Flex- 
ions and  endometritis  are  very  often  the  exciting  and 
direct  cause  of  hystero-epilepsy — a  fact  which  I  have 
demonstrated  by  several  cases  in  my  own  private  practice. 
A  number  of  different  forms  of  uterine  dilators  have 
been  devised,  but  about  all  of  them — like  Sims',  Ellinger's, 
and  Palmers' — diverge  laterally,  and  dilate  the  cervical 
canal  at  the  internal  os  in  a  direction  where  there  is  very 
frequently  no  constriction.  The  advantages  of  this  form 
of  instrument  over  the  ordinary  lateral  dilators  is  best 
shown  by  an  article  by  Dr.  Graily  Hewitt,  in  the  Annals 


THERAPEUTICS. 


321 


of  Oyncecology  of  1888,  from  which  the  above  two  illus- 
trations are  taken.  They  represent  a  well-marked  case 
of  acute  anteflexion,  and  demonstrate  of  themselves  the 
correctness  of  dilating  the  internal  os  and  cervical  canal  in 


Fig.  30. 


^ 


an  antero-posterior  direction.  He 
says,  referring  to  Fig.  27 :  "  The 
uterine  cervical  canal  is  here  hardly 
visible  at  the  centre  and  upper  part 
of  the  cervix,  owing  to  the  closeness 
of  apposition  of  the  anterior  and  pos- 
terior walls,  which  closeness  is  due, 
as  is  manifest,  to  the  presence  of  the 
flexion.  In  Fig.  28  is  shown  another 
illustration  of  the  same  uterus,  but 
the  cervical  canal  on  one  side  (the 
right)  is  opened  out  by  traction  of 
two  threads.  ...  It  is  thus  made 
evident  that  the  cervical  canal  is  not  by  any  means  de- 
stroyed. The  interesting  fact  becomes  evident  that  the 
21 


Fig.  31. 


322  FUNCTioisrAL  nervous  disorders. 

canal  is  unusually  widened  from  side  to  side  at  the  same 
time  that  it  is  so  narrowed  from  before  backward  that  it 
is  hardly  visible  when  the  canal  is  in  its  untouched,  flexed 
state.  In  this  particular  case  the  part  of  the  uterine  canal 
most  affected  by  the  flexion  is  just  below  the  internal  os. 
The  bending  of  the  uterus  produces  a  curvature  of  the 
canal,  which  operates  particularly  on  the  canal  for  about 
three-quarters  of  an  inch.  In  this  space  the  canal  is  ex- 
cessively wide  from  side  to  side,  but  excessively  narrow 
from  before  backward,  and  it  is  manifest  that  the  lateral 
wideninng,  as  well  as  the  antero-posterior  compression  and 
narrowing,  result  from  the  shape  of  Ihe  uterus.  The  in- 
ference also  follows  that  exaggeration  of  the  degree  of  the 
bending  of  the  uterus  would  have  the  effect  of  increasing 
the  compression  of  the  uterine  canal.  It  is  not  easy,  look- 
ing at  this  specimen,  to  avoid  the  conclusion  that  the  es- 
cape of  menstrual  fluid  and  menstrual  debris  from  the 
nterus  must  have  been  very  difficult  so  long  as  the  uterus 
remained  flexed  to  its  present  degree." 

The  accompanying  drawings  demonstrate  the  result  of 
flexion  in  a  simple  rubber  tube :  Fig.  29  represents  a  side 
view,  showing  the  compression  in  the  direction  of  the 
arrows,  while  Fig.  30  is  a  front  view,  showing  the  lateral 
widening.  The  lateral  dilators  cannot  be  made  to  dilate  the 
cervical  canal  in  its  antero-posterior  or  conjugate  diame- 
ter with  any  sort  of  satisfaction,  and  lateral  flexions  are 
extremely  rare.  The  instrument  devised  has  handles 
which  are  most  convenient  to  manipulate,  with  the  regis- 
tering guide  well  out  of  the  way  of  the  fingers,  and  is 
graduated  in  inches  and  in  centimetres,  so  that  one  can 
exactly  determine  the  amount  of  dilatation  and  keep  a 
record  of  it  if  desired.  The  intra-uterine  portion  of  the 
blades  is  but  two  inches  in  length,  as  that  is  all  that  is 


THERAPErTICS.  323 

necessary'.  The  danger  of  injuring  the  fundus  uteri  is 
thus  avoided.  It  gives  the  greatest  dilatation  at  the  inter- 
nal OS,  where  it  is  most  needed.  Of  the  lateral  dilators,  I 
think  Sims'  is  the  best. 

As  to  what  constitutes  stenosis. 

Peaslee  *  says :  "  In  the  imparous  woman  the  narrow- 
est point  of  the  cervical  canal — viz.,  the  internal  os — is, 
when  opened  by  passage  of  the  menstrual  fluid,  an  ellipse 
whose  conjugate  and  transverse  diameters  average,  re- 
spectively, one-sixth  and  one-eighth  of  an  inch,  its  area 
corresponding  very  nearly  with  that  of  a  circle  one-seventh 
of  an  inch  in  diameter.  The  external  os,  also  elliptical 
when  moderately  dilated,  has  diameters  averaging  one- 
fourth  and  one-sixth  of  an  inch.  It  thus  has  an  area  ex- 
actly twice  that  of  the  internal  os,  and  equaling  that  of  a 
circle  one-fifth  of  an  inch  in  diameter.  In  the  parous 
woman  the  size  of  the  external  os  varies  within  quite  ex- 
tensive limits,  since  it  is  exposed  to  so  many  of  the  acci- 
dents of  parturition,  while  the  internal  os  is  more  nearly 
uniform."  He  finds,  as  a  rule,  the  lowest  average  diame- 
ter in  parous  women  who  are  neither  sterile  nor  have 
dysmenorrhoea  to  be  about  one-fifth  of  an  inch,  or  a  little 
less,  at  the  inner  os,  presenting  nearly  twice  the  area  of 
that  of  the  imparous  woman ;  the  external  os,  as  a  rule,  to 
be  about  one-fourth  of  an  inch  in  diameter.  He  believes 
that  in  the  treatment  of  dysmenorrhoea  and  stenotic  steril- 
it}'  these  dimensions  will  be  found  sufficient  in  many 
cases : 

Imparous. — The  internal  os  equals  a  circle  one-seventh 
of  an  inch  in  diameter;  the  external  os  equals  a  circle 
one-fifth  of  an  inch  in  diameter. 

*  E.  R.  Peaslee :  Traasactions  of  the  New  York  Academy  ot 
Medicine,  1876,  p.  428  et  seq. 


324  FUNCTIONAL    NERVOUS    DISORDERS. 

Parous. — The  internal  os  equals  a  circle  one-fiftb  of  an 
inch  in  diameter ;  the  external  os  equals  a  circle  one-fourth 
of  an  inch  in  diameter. 

The  performance  of  trachelotomy  is  now  comparatively 
rare.  There  are  many  cases  of  conoidal  cervix  and  ante- 
flexion in  which  Sims'  sagittal  incision  may  be  performed, 
but  it  is  better  to  try  the  milder  and  safer  method  of  dila- 
tation first. 

Coe  *  says :  "  That  the  incision  of  the  cervix  for  steno- 
sis is  not  an  entirely  harmless  procedure  is  evident  ana- 
tomically as  well  as  clinically.  The  proximity  of  the 
peritoneum  and  the  rich  network  of  veins  which  lies  in 
the  muscular  coat  of  the  uterus  renders  the  danger  of  peri- 
tonitis and  septic  absorption  no  imaginary  one.  The  in- 
dications are  clearly  to  make  the  incision  as  limited  in 
lengtb  and  depth  as  possible,  and  to  practise  rigid  anti- 
sepsis." Bilateral  incision  is  obsolete  as  an  operation  ex- 
cept in  cases  of  conical  cervix  and  pinhole  os,  and  then 
simply  as  preliminary  to  dilatation. 

In  the  treatment  of  these  cases  we  frequently  find  the 
uterus  tender,  with  an  almost  imperforate  cervical  canal, 
swollen  and  occluded  by  tenacious  mucus.  It  is  necessary 
to  have  the  uterus  and  adnexa  prepared  for  the  operation 
of  dilatation  by  the  usual  treatment  for  removing  inflam- 
matory condition,  i.e.,  hot- water  injections,  astringent 
and  detergent  applications,  boroglyceride,  boric  acid,  tam- 
pons, etc.  (Boroglyceride,  an  excellent  preparation,  was 
first  introduced  into  this  country  from  England  by  the 
late  celebrated  J.  Marion  Sims,  where  it  was  first  used  by 
a  Mr.  Balfe  for  preserving  game.)  On  the  table  or  cabi- 
net at  the  operator's  side  there  should  be,  besides  instru- 

*  H.  C.  Coe:   "  American  System  of  Gynaecology,"  vol.  1.,  p.  151. 


THEKAPEUTICS.  325 

ments,  solutions  of  carbolic  acid,  bichloride,  etc.,  a  small 
porcelain,  china,  or  glass  dish  containing  cotton  tampons 
soaked  with  boroglyceride  and  glycerin,  and  others  dry. 
If  they  are  not  ready  prepared,  it  causes  considerable  delay 
while  the  patient  is  on  the  table,  which  is  unpleasant. 
After  cleansing  the  cervix  and  vagina  by  mopping  them 
with  wet  absorbent  cotton,  a  double  tenaculum  is  hooked 
into  the  anterior  lip  of  the  uterus,  and  it  is  drawn  down- 
ward gently.  With  a  hypodermic  syringe,  to  which  a 
silver  intra-uterine  pipe  is  attached,  about  thirty  minims  of 
a  four-per-cent.  solution  of  cocaine  are  injected  into  the 
uterine  cavity,  and  the  external  os  is  plugged  for  a  few 
moments  with  absorbent  cotton.  This  gives  great  relief, 
particularly  in  acute  and  subacute  endometritis  with  pelvic 
pain.  After  a  few  moments  the  dilator  can  be  inserted 
and  the  canal  dilated.  In  some  cases  it  is  necessary  to  pass 
conical  cervical  bougies  before  the  dilator  can  be  used. 
Of  the  usual  forms,  Peaslee's  are  inflexible,  being  of 
steel,  and  Hanks'  are  of  hard  rubber;  two  sets  have 
been  made,  one  of  block  tin  and  the  other  of  copper,  which 
are  flexible,  and  can  be  moulded  without  trouble  to  the 
curves  of  the  uterine  canal.  They  are  to  precede  the 
dilator  when  the  canal  is  too  small  for  its  introduction. 
The  block-tin  sounds  can  also  be  used  as  obturators  for  in- 
serting the  tracheal  cannula.  Ordinarily,  half  an  inch  is 
as  far  as  dilatation  should  be  carried.  The  patient  should 
be  in  the  Sims  position.  The  operation  can  be  done  in 
many  cases  at  the  physician's  office,  but  the  uteri  of  some 
women  have  a  habit  of  getting  up  a  severe  inflammation 
on  very  slight  provocation,  so  it  is  safer  to  do  the  operation 
at  the  patient's  home,  and  then  with  all  antiseptic  precau- 
tions. The  instruments  are  to  be  washed  in  hot  soap  water 
to  remove  adherent  mucus,  and  then  in  clean  water,  dried, 


326 


FUJfCTIOJSTAL    XERVOUS    DISOEDERS. 


and  passed  through  the  flame  of  a  spirit  lamp,  thus  destroy- 
ing all  germs,  which  boiling  water  does  also.  It  does  not 
discolor  the  instruments  or  "give  them  the  blues,"  and 
they  are  finally  placed  in  a  three-per-cent.  carbolic-acid 


Fig.  33. 

solution.  In  rare  cases,  when  an  in- 
cision is  required  at  the  internal  os  on 
account  of  the  fibrous  band  or  induration 
at  the  compressed  angle  of  flexion,  I  have 
had  a  knife  made  with  a  metallic  handle 
flexible  below  the  blade,  yet  strong  enough 
to  resist  any  ordinary  pressure  for  cut- 
ting-purposes. It  is  one-eighth  of  an  inch 
broad  at  the  base  and  one-sixteenth  near 
the  point,  with  a  rounded  point  and  back. 
A  Sims  or  Emmet  intra-uterine  knife  can 
be  used,  but  they  are  much  more  expen- 
sive. After  the  blades  of  the  dilator 
have  been  sterilized  by  passing  them 
through  the  spirit  flame,  they  are  well 
greased  and  introduced.  The  handles  are 
pressed  gently  and  slowly,  until  the  guide 
shows  that  half  an  inch,  or  a  little  over 
a  centimetre,  separates  the  blades.  After  cleansing  the 
uterine  cavity  with  an  antiseptic,  the  intra-uterine  stem  is 
inserted  and  allowed  to  remain,  the  patient  drawing  it 
away  by  the  silk  thread  if  it  causes  any  irritation.  The 
stem  (Fig.  32)  has  been  modified  hj  giving  it  a  retaining- 


Fig.  3.3. 


THEEAPEUTICS. 


327 


swell,  which  adapts  itself  to  the  normal  shape  of  the  cervi- 
cal canal  between  the  external  and  internal  os  and  pre- 
vents it  from  slipping  out  if  the  proper  size  has  been  used. 
The  principle  involved  in  the  intra-uterine  stem  is  the  same 
as  in  Dr.  O'Dwyer's  tubes  for  stenosis  of  the  larynx,  from 
which  the  idea  of  the  retaining-swell  and  the  perforation 
for  the  thread  for  its  withdrawal  was  copied.     The  special 


Fig.  34. — Stenosis  Case. 

forceps  (Fig.  33)  for  introducing  the  stem  holds  it  very 
firmly  during  its  insertion.  Messrs.  Tiemann  &  Co.  have 
put  the  instruments  in  a  case  (Fig.  34),  which  also  contains  a 
rather  heavy  uterine  probe  to  determine  the  direction  of  the 
canal.  One  is  led  to  believe  that  the  treatment  of  the  fore- 
going conditions  by  dilatation  is  both  rational  and  scien- 
tific. It  is  of  course  applicable  to  chronic  cases  only,  and 
is  a  delicate  procedure,  requiring  skill  and  good  judgment. 


Cold. 

Cold  acts  on  the  vasomotor  system  as  a  neurotic  irri- 
tant. As  a  tonic  it  produces  a  shock  which,  if  not  too 
great,  is  always  followed  by  a  reaction.     This  exercises 


328  FUNCTIONAL   JSTERVOrS    DISORDERS. 

the  system,  and  thus  tends  to  improve  the  nutrition  and 
strengthen  the  bodj^,  or  the  part  to  which  it  is  applied.  It 
is  a  tonic  in  cases  of  weak  circulation  and  feebleness  of  mus- 
cular power.  It  strengthens  the  heart  and  the  arteries. 
It  improves  the  digestion.  During  a  cold  bath,  be  it  dip, 
shower,  or  sponge,  great  care  should  be  taken  that  the 
patient  does  not  become  exhausted  by  its  too  long  continu- 
ance. Five  minutes  is  a  sufficient  length  of  time  for  any 
one.  Reaction  should  be  favored  by  massage  and  the  use 
of  the  flesh  brush. 

In  migraine  with  dilation  of  the  temporal  artery  and 
congestion  of  one  eye,  in  cerebral  congestion  from 'sun- 
stroke, strong  coffee,  or  tea,  and  in  nasal  hemorrhage 
great  relief  is  often  obtained  by  cold  applications  to  the 
nape  of  the  neck.  Cold  acts  as  a  styptic  hj  lessening  the 
calibre  of  the  arteries  through  its  irritant  effect  upon  the 
vasomotor  nerves.  By  its  irritation  of  the  afferent  nerves 
it  causes  not  only  a  variation  in  the  calibre  of  the  vessels 
of  the  surface  of  the  part  to  which  it  is  applied,  but  also  in 
all  the  arteries  directly  beneath  that  part.  When  the 
organs  of  the  body  are  in  pairs  and  perfectly  symmetrical, 
as  is  the  case  with  the  eyes,  cheeks,  ears,  hands,  and  feet 
(the  kidneys,  testicles,  and  lungs  are  not),  any  variation  in 
the  calibre  of  the  vessels  of  one  will  cause  a  like  variation 
in  the  calibre  of  the  vessels  of  the  other.  Variations  also 
in  the  calibre  of  the  vessels  of  certain  parts  of  the  body 
are  attended  by  corresponding  changes  in  the  arteries  of 
certain  other  parts.  These  associations  have  been  deter- 
mined empirically;  thus,  the  interdependence  of  the  con- 
dition of  the  circulation  of  the  feet,  the  abdominal  and 
pelvic  organs,  and  the  pharynx,  as  well  as  that  in  the  nape 
of  the  neck  with  the  arteries  of  the  brain  and  face,  is  well 
known.     Dr.  William  M.  Thomson,  of  New  York,  has  in 


THEEAPEUTICS.  329 

his  lectures  noted  the  laws  of  the  vasomotor  sj'stem,  and 
their  response  to  the  action  of  cold. 

An  ice  bag  or  ether  spray  applied  to  the  epigastrium 
stops  hsematemesis. 

Holding  a  piece  of  ice  in  one  hand  will  check  bleeding 
in  the  other.  A  cold  footbath  will  arrest  metrorrhagia,  as 
will  also  ice  rubbed  against  the  inner  aspect  of  the  thighs 
and  across  the  abdomen.  In  post-partum  hemorrhage  the 
cold  should  be  applied  by  means  of  the  ether  spray,  for  the 
sudden  and  intense  impression  which  it  makes  causes 
effectual  uterine  contraction  without  chilling  the  patient. 

When  the  ether  is  not  available,  ice  water  may  be 
poured  from  a  moderate  height,  but  this  is  rarely,  if  ever, 
necessary.  Slapping  the  thighs  and  abdomen  with  cloths 
or  towels  wrung  out  in  ice  water  is  more  convenient  and 
in  every  way  better. 


330  FUXCTIONAL   XERYOUS   DISORDERS. 


Literature. 

Anderson,  T.  :  British  Medical  Journal,  February  8,  1879. 

Baruch,  Simon :  Uses  of  Water  in  Modern  Medicine.  Deti'oit, 
1893. 

Bastian,  H.  Charlton  :  Paralysis.     New  York,   1886. 

Bastian,  H.  Charlton  :  Brain  as  an  Organ  of  the  Mind.  New- 
York,  1880. 

Bastian,  H.  Charlton:  Various  Forms  of  Hysterical  or  Functional 
Paralysis.     London,  1893. 

Bauduy,  Jerome  K.  :  Diseases  of  the  Nervous  System.  Philadel- 
phia, 1892. 

Beard  and  Rockwell  •  Sexual  Neurasthenia.     New  York,  1894. 

Beard  and  Eockwell :  Medical  and  Surgical  Electricity.  New 
York,  1871. 

Beard,  G.  M.  :  Nervous  Exhaustion.     New  York,  1880. 

Boldt,  H.  J.  :  Cardiac  Neuroses.  American  Journal  of  Obstet- 
rics, August,  1886.  Reflex  Vaso-Motor  Neurosis  (Blue  CEdema) . 
lUd.,  February,  1886. 

Bosworth,  F.  H.  :  The  Relation  of  Vaso-Motor  Disturbances  to 
Diseases  of  the  Upper  Air-Tract.  New  York  Medical  Journal, 
November  23,  1895. 

Bourneville  et  Reynard  :  Iconographie  Photographique  de  la  Sal- 
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Bourneville  et  D'Olier:  Recherches  sur  I'Epilepsie,  I'Hysterie, 
et  ridiotie.     Progres  Medical,  1881. 

Bramwell,  Byrom :  The  Diseases  of  the  Spinal  Cord.  Edin- 
burgh, 1882. 

Briquet :  Traite  Clinique  et  Therapeutique  de  I'Hysterie.  Paris^ 
1859. 

Bristowe,  John  Syer  :  Diseases  of  the  Nervous  System.  London, 
1888. 

Brodie,  Sir  Benjamin  C.  :  Local  Nervous  Affections.  London,. 
1837. 

Brown,  Ralph:  Neurasthenia.     London,  1894. 

Brown-Sequard,  C.  E.  :  Lectures  on  the  Diagnosis  and  Treatment 
of  Functional  Nervous  Affections.     New  York,  1868. 

Brown-Sequard,  C.  E.  :  Legons  sur  les  Nerfs  Vaso-Moteurs. 
Paris,'  1892. 

Carpenter,  William  B.  :  Mental  Physiology.     London,  1874. 

Carter,  Robert  Brudenell :  Hysteria.     London,  1858. 

Chapman,  John  :  Neuralgia.     London,  1893. 

Charcot,  J.  M.  :  Legons  sur  le  Systeme  Nerveux.  Paris,  1873  and 
1884. 


LITEKATURE.  331 

Charcot,  J.  M.  :  Ciinique  des  Maladies  du  Systeme  Nerveux. 
Paris,  1373. 

Clevenger,  S.  V.  :  Spiual  Concussion.     Philadelphia,  1889. 

Clouston,  I.  S.  :  The  Neuroses  of  Development.     London,  1891. 

Collins,  Joseph  :  Angeio-Neurotic  CEdema.  American  Journal 
of  the  Medical  Sciences,  December,  1892.  New  York  Medical  Record, 
April,  1892. 

Conklin,  W.  J.  :  Some  Neuroses  of  the  Menopause.  Transactions 
of  the  American  Association  of  Obstetricians  and  Gynaecologists, 
1889. 

Cowles,  Edward :  Neurasthenia.     Boston,  1891. 

Dana,  Charles  L.  *New  York  Medical  Journal,  July,  1887. 

Dana,  Charles  L.  :  Text-Book  of  Nervous  Diseases.  New  York, 
1892. 

Davey,  James  George  :  The  Ganglionic  Nervous  System.  Lon- 
don, 1858. 

De  la  Toui'ette,  Gilles.  Traite  Ciinique  et  Therapeutique  de 
I'Hysterie.     Paris,  1895. 

Dubois,  Frederic  :  Hypochondrie  et  Hysterie.     Paris,  1837. 

Edebohls,  G.  M.  :  New  York  Journal  of  Gynaecology  anil  Obstet- 
rics, January,  1893. 

Emmet,  Thomas  Addis  :  Principles  and  Practice  of  Gyneecology. 
Philadelphia,  1884. 

Emminghaus,  H.  ;  AllgemeinePsychopathologie.     Leipsic,  1878. 

Engelmann,  George  J.  :  Gynaecological  Transactions,  1877  and 
1887. 

Etheridge,  James  H.  :  Medical  Gynecology.  American  Journal 
of  the  Medical  Sciences,  January,  1892. 

Eulenburg,  Albert :  Lehrbuch  der  Nervenkrankheiten.  Berlin, 
1878. 

Evans,  W.  F.  :  Mental  Medicine.     Boston,  1895. 

Goodell,  W.  :  Lessons  in  Gyneecology,  Lessou  XXX.  Philadel- 
phia, 1880. 

Gowers,  W.  R.  :  Diseases  of  the  Nervous  System,  vol.  ii.  Lon- 
don, 1888. 

Grasset,  J.  :  Maladies  du  Systeme  Nerveux.     Paris,  1886. 

Gray,  Landon  Carter :  Nervous  and  Mental  Diseases.  Philadel- 
phia, 1893. 

Gross,  Morris:  New  York  Medical  Journal,  May  4,  1895. 

Hamilton,  AlJan  McLane :  Nervous  Diseases,  their  Description 
and  Treatment.     Philadelphia,  1878. 

Hammond,  William  A.  :  A  Treatise  on  Diseases  of  the  Nervous 
System.      New  York,  1881. 

Hammond,  William  A.  :  Spiritualism  and  Allied  Causes  and 
Conditions  of  Nervous  Derangements.     New  York,  1876. 

Hart  and  Barbour  :  Manual  of  Gynecology.     New  York,  1883. 


332  FUNCTIONAL   NERVOUS    DISORDERS. 

Hartshorne,  Henry:  Reynolds' System  of  Medicine,  vol.  i.,  1880, 

Heiberg,  J.  :    Atlas  of  the  Cutaneous  Nerve  Supply.     London, 
1888. 

Herter,  Christian  K.  :  The  Diagnosis  of  Diseases  of  the  Nervous 
System.     New  York,  1892. 

Hilton,  John  :  Rest  and  Pain.     New  York,  1879. 

Horsley,  Victor  ;  The  Structure  and  Functions  of  the  Brain  and 
Spinal  Cord.     Philadelphia,  1894. 

Jauch,  P.  L.  :  Automatisrae  Psychologique.     Paris,  1894. 

Jolly,  F.  :  Ziemssen's  Cyclopedia  of  Medicine.     New  York,  1877. 

Jones,  C.  Handfield.  Studies  in  Nervous  Functional  Disorders. 
London,  1870. 

Krafift-Ebing,  R.  von :  Lehrbuch  des  Psychiatrie.  Stuttgart, 
1883. 

Kraflft-Ebing,  R. von  (Chaddock,  C.  G. ,  translator):  Psychopathia 
Sexualis,     Philadelphia,  1892. 

Laycock,  Thomas  :  Nervous  Diseases  of  Women.   London,  1840. 

Lee,  Charles  Carroll :  The  Relation  of  Periplieral  Irritation  to 
Diseases  of  the  Womb  and  its  Appendages.  Annals  of  Gyneecology 
and  Paediatry,  June,  1890. 

Leszynsky,  William  M.  :  New  York  Medical  Journal,  March, 
1891. 

Lloyd,  James  Henr3^ :  Hysteria  (Nervous  Diseases  by  American 
Authors).     Philadelphia,  1895. 

Mann,  Edward  C.  :  Manual  of  Psychological  Medicine  and  Allied 
Diseases.     Philadelphia,  1883. 

Maudsly,  Henry  :  Pathology  of  the  Mind.     New  York,  1880. 

McGillicuddy  :  New  York  Medical  Journal,  August  1888. 

McGillicuddy  :  New  York  Medical  Journal,  November,  1893. 

McGillicuddv  :  Dietetic  and  Hygienic  Gazette,  January,  1895. 

McGillicuddy  :  Transactions  of  the  New  York  State  Medical  Asso- 
ciation, vol.  vii.,  1890. 

McGillicuddy  :  New  York  Medical  Record,  October,  1894. 

McGillicuddy  :  New  York  Medical  Record,  November,  1895. 

Mills,  Chas.  K.  :  Hystero- Epilepsy.  American  Journal  of  Medical 
Sciences,  October,  1881 ;  and  System  of  Medicine,  Pepper,  1886. 

Mitchell,  J.  K.  :  Massage.     Medical  News,  1893. 

Mitchell,  J.  K.,  and  de  Schweinitz,  G.  E.  :  A  Further  Study  of 
Hysterical  Cases  and  their  Field  of  Vision.  Journal  of  Nervous  and 
Mental  Disease,  New  York,  1894. 

Mitchell,  J.  K.  :  Notes  on  the  Effects  of  Massage  on  the  Blood 
Current.  Transactions  of  the  College  of  Physicians,  Philadelphia, 
1893. 

Mitchell,  J.  K.  :  The  Effect  of  Massage  on  the  Number  and  Hae- 
moglobin Value  of  the  Red  Blood  Cells.  American  Journal  of  the 
Medical  Sciences,  Philadelphia,  1894. 


LITERATURE.  333 

Mitclipll,  S.  Weir :  Wear  and  Tear  of  the  Nervous  Sj^stem. 
Philadelpliia,  1887. 

Mitchell,  S.  Weir :  Fat  and  Blood,  and  How  to  Make  Them. 
Philadelphia,  1888. 

Mitchell,  S.  Weir:  Lectures  on  the  Diseases  of  the  Nervous 
SystPm,  Especially  in  Women.     Philadelphia,  1885. 

Mitchell,  S.  Weir :  Hysterical  Rapid  Respiration,  with  Cases. 
American  Journal  of  the  Medical  Sciences,  Philadelphia,  March, 
1893. 

Nebel,  Hermann  :  The  Mechanical  TreatTuent  of  Chorea.  Con- 
tribution to  Mechanico-Therapeutics  and  Orthopasdics,  vol.  i.,  No.  3. 

Osier,  William  :  On  Chorea.     Philadelphia,  1894. 

Peterson,  F.  :  Hydrotherapy  in  the  Treatment  of  Nervous  and 
Mental  Diseases.  American  Journal  of  the  Medical  Sciences,  Phila- 
delphia, 1893. 

Playfair,  W.  S.  :  The  Systematic  Treatment  of  Nerve  Prostration 
and  Hysteria.     London,  1883. 

Putzel,  L.  :  Common  Forms  of  Nervous  Diseases.  New  York, 
1880. 

Richer,  Paul :  Etudes  Cliniques  sur  la  Grande  Hysterie  ou  Hys- 
tero-Epilepsie.      Paris,  1885. 

Roose,  Robson  :  Nerve  Prostration.     London,  1888. 

Rosenthal,  M.  :  Clinical  Treatise  on  the  Diseases  of  the  Nervous 
System.     London,  1881. 

Ross,  James  :  Diseases  of  the  Nervous  System.     New  York,  1883. 

Sachs,  B.  :  Nervous  Diseases  of  Children.     New  York,  1895. 

Segnin,  Edward  C.  :  Opera  Minora.      New  York,  1884. 

Smith,  Charles  N:  Vaso-Motor  Neuroses  of  Pelvic  Origin. 
American  Journal  of  Obstetrics,  vol.  xxiii.,  No.  11,  1890. 

Starr,  M.  Allen :  Familiar  Forms  of  Nervous  Disease.  New 
York,  1891. 

Stevens,  G.  F.  :  Functional  Nervous  Disorders.     New  York,  1887. 

Sturges,  O.  :  Medical  Examiner.      London,  1876. 

Todd,  Robert  B.  :  Lectures  on  Paralysis.      Philadelphia,  1855. 

Tilt,  Edward  John  :  The  Change  of  Life.     New  York,  1882. 

Tuke,  Daniel  Hack :  Influence  of  the  Mind  upon  the  Body. 
Philadelphia,  1884. 

Van  de  Warker,  Ely  :  American  Journal  of  the  Medical  Sciences, 
November,  1892. 

Webber,  Samuel  G.  :  Treatise  on  Nervous  Diseases.  New  York, 
1885. 

Wischnewetzky,  L. ;  Contribution  to  Mechanico-Therapeutics  and 
Orthopedics,  vol.  i..  No.  2. 

Wood,  H.  C.  :  Nervous  Diseases  and  their  Diagnosis.  Phila- 
delphia, 1887. 


334  FUNCTIONAL    NERVOUS    DISOEDERS. 

Zander,  Gustaf  :  The  Mechanico-Therapeutic  Institute.  Contri- 
bution to  Mechanico-Therapeutics  and  Orthopgedics,  vol.  i,  No.  1. 

Zander,  Gustaf :  Mechanico-Therapeutics  and  Orthopaedics  bj^ 
Means  of  Apparatus.  Contribution  to  Mechanico-Therapeutics  and 
Orthopaedics,  vol.  i..  No.  2. 

Ziemssen,  H.  Yon ;  Cyclopeedia  of  the  Practice  of  Medicine. 
New  York,  1877. 


PREFATORY  NOTE  TO  THE  APPENDIX. 


The  study  of  a  subject  is  simplified  and  made 
more  interestlDg  when  the  verbal  descriptions  are 
supplemented  by  illustrative  charts,  plates,  or  dia- 
grams. Such  devices  assist  in  clearing  up  any 
obscurities  in  the  text  and  are  often  of  value  in 
medicine  in  obtaining  a  correct  diagnosis.  The 
author  has  devised  the  following  series  of  charts 
with  the  hope  that  they  will  serve  a  good  purpose 
in  illustrating  some  points  in  a  rather  obscure  yet 
important  branch  of  medical  science. 


£35 


CHART  I. 


iTical  Aphonia  l 

'■  Apnoea 

"  Dysphagia        ' 

"  Laryngismus    I 

"  Strangulation  ] 

"  buffooatioii      J 


Glolius  Hystericus 


Contractui'es 


Paraplegias 


Contractures 


Mental  Depression,  Loss  of 
Memory,  Excessive  Irri- 
tability, Wakefulness,  In- 
tense Lethargy,  Day 
Drowsiness  or  Narcolep- 
sy, Morbid  Fears,  Hyp- 
notism, Trance,  Catalep- 
sy, homnambulism, 
Neura-sthenia.  Anaesthe- 
sias, Hystero-Epilepsy  or 
Hysteria  Major,  M  e  1  a  u- 
cholia,  Mania 


Joint  Neuroses 


CEREBRAL  REFLEX  NEUROSES 


22 


CHART   11. 


Hyperehlorhydria 
(A  Primary  Neu- 
rosis in  Melan- 
cholia and 
Hysteria) 


Dyspepsia  ) 
DiaiThoia   ) 
(From  Mental 
Emotion) 


Amenorrhoea 
(Due  to  severe 
Mental 
Disturbances) 


■;■  Anachlorhydria 
(A  Retiex  in  the  Hys 
terical  and  the 
Neurasthenic) 


f  Intei-mittency 
I  IrregTilai-ity 
■  Cardiac   i  Palpitation 

:  Bracliycardia  (J) 
I  Tachyeardia(0 


(  Enuresis 
'(  Polyuria 

(Reflexes  from  Men- 
tal Excitement) 


CEREBRAL   REFLEX   NEUROSES-Continued 


CHART  Hi. 


SPINAL  REFLEX  TENDERNESS  ARISES  USUALLY  FROM  IRRITATION  IN  THE    DIGESTIVE  TRACT— FROM 
MENTAL  EMOTIONS;  POISONS  OF  VARIOUS  FEVERS-FROM  UTERINE  DISORDERS. 


Cervico-occipital  pain 

(In  Uterine  Disease) 


f     Reflex  tenderness  of  Cer- 
vical   and     Upper    Dorsal 
I  Spine    frequeiitly    accom- 
panies Gaslralgia,  Nausea, 
Vomiting,     and     Stomach 
Disease  ot  different  types— 
Ulcus  and  Hypersecretiiai 
of  Hydrochloric  Aci<l — Pain 
is   between    the    Slioulder 
,  Blades— TlieUpperExtrem- 
i  ities  may  also  be  affected — 
This  may  be  from  directlr- 
I  ritation  of  the  Coeliac  Gan- 
L  glia  of  the  Sympathetic 


Pains  and  Inflammatory 
conditions  of  the  Lower 
Abdomen,  Bladder,  Genital 
Organs,  and  Lower  Extrem- 
ities cause  Reflex  Spinal 
Tenderness  in  this  region- 
Lower  Dorsal  and  Lumbar 
—Most  common  m  Uterine 
.  Affections- Endometritis 


SPINAL  REFLEX  NEUROSES 


341 


CHART  IV. 


Ringing,  Paroxysmal  Cough 
(Dependent  ou  Pregnancy) 


Asthma 
(From  Uterine  Retroflexion) 


(Treni  Irritation  in  Digestive 
Tract) 


./  Bronchial  Irritation 

(Due  to  Chronic  (Jastric 
Catarrh) 


Unilateral  Perspiration 


'  Cheyne-Stokes  Kesptration 
(From  Pelvic  Disease) 


BRONCHIAL  REFLEX   NEUROSES 


343 


CHART  V, 


stomachal  Vertigo 


Asthenopia 
J  imness  of  Vision 
Ptosis 
(Reflex  from  Digestive  and 
Uterine  disorder) 


Angeio-spastic 
graine,    a  com   I 
mon  Gastric  Neu  | 
rosis^Migraine  | 
and   Toe   Crarap'!   , 
frequentandinter  I 
changeable   symp- 
toms resulting 
from  indigestion 


Reflex 

from 

Gastric 

Disease 


Hay  Fe\  ei 


Dysmenorrhoea 
(Reflex  from  Chronic 
Gastric  Catanh) 


Fingers  Ansestlietic  or  ? 

Neuralgii- 

(So-called  ''wind 

pains") 


Gastric  Headache — Frontal 


(Giant  Lrtiearia,  or  Angeio- 
neurotic  OSdenia  of  Larynx 
and  Dorsum  of  the  Hand 
(Dut,  to  Chronic  Indigestion) 


Asthma 

(Reflex  from  Gastric 
causes) 


f  Angina      Pectoris 
and   Pseudo-An- 
gina, witli  Left- 
'.     Arm  Cramps 
I  Anaesthesia 
I  Neuralgia 
L  Palpitation 
(From  Gastric  Irri- 
tation)— 


f  Angeio-spastic 
I  Cramps     in     the 
I     Call,  Leg  Aclie 
I  G  a  s  tro-intestinal 
i     Neuroses—  Com- 
I     mon  in  Cholera, 

Dial)etes,  etc. 
i  Sharp  pains  in  tho 
I     calf 

(Frequently  due  tc^ 
Indigestion  from 
strong  coffee) 


GASTRIC    REFLEX    NEUROSES 


345 


CHART    VI. 


Headaches         I 
Uterine  Origin ) 


Swelling  of 
Face,  Arm,  and 

Hand 

(A  Menstrual  NeU' 

rosis) 

Ovarian  Hyper-' 
testhesia,  caus- 
ing  Hyt-tero- 
e  p  i  1  e  p  s  y— If 
Inflammation 
is  severe  the 
pain  Is  in- 
creased by 
pressure 


Duninution  of 

secretion  of 

Hydrochloric 

Acid 

(Reflex  from  Men' 

stniation— E. 

Fleischer) 


Tingling  of  the 

Fingers  and 
SwelUng  of  the 
Ball  of  the 
Thumb 
(A  menstrual  Neu- 
rosis) 


Excessive  Secre 
tioii  of  Hydro-   [-   .• 
chloiic  Acid 
( \  Reflex  after 

Coitus— M.  Gross) 


Pain  in  Heel 
(Reflex  from 
Ovarian    Disease) 


(      Pharyngeal 
Congestion, 
( Chanire  of  Voice 
(With  Puberty) 


Neuralgia,Uterine 

(Common 

in  Pregnancy) 


f  Asthma,         1 

1  Uterine  I  jj 

Dyspnoea,       !  o 
Uterine  f  ^ 
Cough,  X 

Uterine  J 
Quiverings  o  f 
Abdomen,  Gas- 
tric Flatulence, 
Pyrosis,  Acidity, 
Dyspepsia(Uter- 
ine).  Epigastric 
J,  SwellingorTym- 
panitic  Disten- 
tion, Nausea  and 
Vomiting  (con- 
stant), of  Men- 
struation and 
Pregnancy, 
Faintness,  An- 
orexia, Bulimia, 
Belching  (ac- 
company ing 
Menstrual  Con- 
gestion, Morbid 
Appetites  or 
L  Cravings) 


.  Wrist  Pains 
(From  Ovarian 


Hystero- 
Neuroses  of  the 

Joints 
Hip 
Knee 
Ankle 


(  Contractures  of 
(         the  Toes 
(Accompanying 
the  earlier  Men- 
strual periods) 


HYSTERO-NEUROSES 


347 


CHART  VII. 


Salivation,  or  Hypersecretion 
(Reflex  from  Menstraation,  and 
Early  Symptom  of  Pregnancy) 


Thyroid  Enlargement 
(From  Uterine  Irritation) 

Mammary  Swellings 
(Keflex  from  Ovarian  or  Uter- 
ine disease) 
Mastodynia.  oi-  Neuralgia  Mam- 

ma3  (Menstrual)  f 

Congestion  of  Mammary  Glands 
(Keflex  from  M^nstiuatiou, 

or  Concept  ion)  j 


Hyoerseeretion  of  Gas-) 
trie  Juice,  and  Hyper-  J 
chlorliydria  ) 


A  Pensoiy  Neurosis, Gland- 
ular—(Ewald) 


Hepatic  Congestion  and  Jaundice 

(Reflex  from  Disturbed 

Emotions) 


Gail-Stone  Colic  causes  Reflex 
Temporary  Hypoclilorhydria 


j  Suppression  of  Secretion  of 

/     I'arotid  Gland 
(Due   to   reflex    from    Diseased 
Ovary ,  and  Parotiditisenusesre- 
flexly,  tlirough  Sympathetic,  a 
painful  oophoritis) 


j  Seborrhoea  and  Axillary  Per- 
(     spiration 

(Reflex  from  Indigestion) 


Renal  Calculi 


(Cause  Hyperchlorhydria 
Ueflexly) 


( Excessive  Perspiration  of  Hands 
(     and  Feet 

(Reflex  from  Digestive  Disorder) 


Many  of  the  Glandular  Neuroses 
have  been  elassitied  unuei- other 
headings,  such  as  Dermal,  In- 
testinal, Kenal,  etc. 


GLANDULAR   REFLEX    NEUROSES 


349 


CHART  VIII. 


(Common  in  Indigres- 
tioii  from  Coarse 
Vegetable  Food) 

Asthenopia 

(From  Chronic  Gastnc 
Catarrh) 


Ptosis 
(Due  to  Liver 
Disorder) 


Mydriasis    (Intestinal 

Parasites) 
Myosis(ConstipatioE)    ) 


Mouches  Volantes  ;' 
(From  Endome- 
tritis and   Pelvic 
Cellulitis)    Also  a 
Renal  Keflex  (!) 


Hemeralopia  cNight- 
bliudness) 

Ny  etal  opia  .(Day-blind- 
ness 

(Menstrual  Neuroses!) 


f  4.'"a"rosi8(Mensti-ual) 
( Amblyopia  " 


{  Amiurosis  (Hysterical) 
t  (Puerperal) 


( Strabismus  (Hys- 
(     terical) 
(Due  also  to  Worms) 


( Disturbances  of 
I     Acoommodation 
(Due  to  Indigestion) 


Dimness  of  Vision 
x_        (From  Abdominal 
■^^^^^     and  Pelvic  Disease) 


Photophobia 

(From  Uterine 
Disease) 


REFLEX  OPHTHALMIC   NEUROSES 


351 


CHART    IX. 


Anasmic  roarings 
(Keflex  from  Uter- 
ine Polypoid 
growths) 


(Reflex  from  Preg- 
nancy) 


[■  Cracklings, 
j  whistlings,  loud 
]  explosions  like 
[  pistol-shots 
(Reflex  from  Uter- 
ine or  Gastro-ln- 
testinal   Disorder) 


(     Piiffiug,  like 
^  that  of  a  start- 
(  ing  locomotive 
(Reflex  from  Ova- 
rian Disease,  com- 
mon as  an  Aura 
in  Hystero- 
epilepsy> 


REFLEX    AURAL    NEUROSES 


23 


CHART  X. 


Chloasma  a  n  d  1 
Sallow  Com- J- 
plexion  ) 

(Due  to  Faecal  Im- 
paction) 


Pntrittis  Nasi 
(Due  to  rectal  Ir- 
ritation, from 
■\Vorms  or  Hsem- 

orrhoids; 

Chronic  Redness 

(Due  to  Uter:ne 
and  Difrestive 
Derangements) 


Hyperaesthesia  1  C 

Anaesthesia.  r  2 

Perverted  Sensibility '  ^ 

(Due  to  Genito-Urinary, 

or  Gastro-Intestinal 

Disturbances) 


2rer;<^--^ 

Haemorrhagio  Persptra-  i 
tions  occurring  at        J 

Menses 


Urticaria    ) 
Hives 
Xettlerash  > 


(From  Ingestion 
of  Shellfish  and 
other  Indigestible 
Foods) 


f  Erythema  Uterl- 
I     nuiii 
(Chloasma  XTteri- 
nuiii 


Acne  Rosacea, 
with  Xasal  Red- 
ness, Eruptions 

(Due  to  Gastric 
Disease) 


( Pigmentation  of 

(     Areola 

(Reflex  from  Preg- 


Pruiitus  fFrom  Diges- 

tn  e  Disorder) 
Flushes  )  From  l>i- 

Pei-^pirations  -  gestlve 
L  Seborrhoea      *   or  Uter- 
ine Disorder 


f  Abdominal  CThlo- 
I  asmata  or  the 
\  Brownish  Discol- 
oration of  Preg. 
I    nancy 


Herpes  of  Pudenda 
(Due  to  Metritis) 


(Due  to  Obstruction 
of  Portal  Crrcula- 
tion  from  Conges 
tion  of  Ljvei) 
Severest  at  ileno- 
pause 


REFLEX    DERMATIC   NEUROSES 


353 


INDEX. 


Abdomen  almost  black,  152 
Abdominal  flushing,  61 
Accommodation,    disturbances    of, 

128 
Achromatopsia,  197 
Acne  rosacea,  150,  152,  153 
Aconite  in  neuralgias  and  nervous 

headaches,  316 
Affections  of  microbic  origin,  253 

of  the  spinal  cord,  36 
Alexander's  operation,  105 
Alimentation  and  hygiene,  269 
Alkaline  baths,  156 
Amaurosis,  complete  or  incomplete, 
164 

gravidarum,  128 

hysterical,  128,  159 

transitory,  128 
Amblyopia,  128,  197 

hysterical,  129 

transitory,  128 
Amenorrhoea,  27 

aconite  in,  316 
Ani-emia,  5, 139, 157,  252 
Anfemic  headaches,  235 
Anaemic  roaring,  137 

unilateral,  138. 
Anaesthesia,  27,  197 
Analgesia,  196 

Angeio-neurotic  oedema,  77,  82 
Angina  pectoris,  52, 124 
Animal  food,  293 
Anorexia  at  menses,  89,  91 
Anorexia,  description  of,  178 

hysterical,  178 
Antispasmodic  agents,  303 
Anuria,  96 
Aortic  plexus,  22 


Aphonia,  hysterical,  27,  31,  165 
Apncea,  hysterical,  27,  29 

reflex,  10 
Apoplexia,  130 
Arnold,  255 
Arsenic,  156,  299 

Arthralgias  in  uterine  disease,  16 
Arthropathies,  80 
Articular  reflex  neuroses,  144 
Artificial  production  of  the  meno- 
pause, 73 
Asafoetida,  303 
Assimilation,  291 

imperfect,  273 
Asthenopia,  128,  129 
Asthma,  5,  306,  316 

hysterical,  166 

spasmodic,  309 
Ataxia,  forms  of,  132 
Atrophy  of  cheek,  131 

progressive  muscular,  132 
Atropine     in     localized    muscular 
spasm,  309 

in  reflex  asthma,  308 

in  salivation,  308 
Auditory  nerve,  138 
Aura  hysterica,  194 
Aural  reflex  neuroses,  137 

symptoms  and  abdominal  cav- 
ity, 138 

symptoms  and  chest  disease,  138 
Australian  blight,  79 
Autoinfection  a  cause  of  symptoms, 
137 

Bacon,  181 

Bacteria,  259 

Bacterial  development,  260 


357 


358 


INDEX. 


Bactericidal    properties    of    blood 

serum,  261 
Bacteriological  origin  of  disease,  252 
Barker,  7 
Basic  malady,  252 
Bath,  practitioners  at,  256 
Belching  and  vomiting  accompany- 
ing menstrual  congestion,  89 
Belladonna,  307 

in  globus  hystericus,  308 
Bichromate  of  potassium  in  bromi- 

drosis,  127 
Bidder,  255 
Bladder,  i 

functional  disturbance,  98 

neurotic  disturbance,  108 

treatment,  109 
Blepharospasm,  hysterical,  164,  165 
Blue  hysterical  oedema,  176 
Blurring  of  vision,  130,  188 
Boix,  176 

Boldt  on  cardiac  neuroses,  7 
Borborygmus,  hysterical,  166,  194 
Boulimia.  89 

Braithwaite  on  codeine,  83 
Briquet,  189,  194 
Brissaut,  179 

Bristowe  on  hysteria,  159,  160 
Broad  conception  of  disease,  252 
Brodie,  146 

Broken-down  constitutions,  259 
Bromides,  305 
Bronchial     and    cardiac    neuroses 

often  combined,  85 
Bronchial  hystero-neurosis,  87 
Bronchial  reflex  neuroses,  85 

causes  of,  85 
Brunton  on  condurango,  299 
Burning  sensations  of  tongue,  141 

hysterical  origin  of,  141 

Cafe  mir,  298 
Caffeine,  298 
Calculus,  4 
Calumba,  299 
Camphor,  303,  317 
Cannabis  indica,  315 
Cardiac  disease,  5 

irritations,  27 

neuroses   in    connection    with 
ovarian  and  uterine  disease,  7 


Cardiac  palpitation,  27,  194 
Cardiac  reflex  neuroses,  42 

dependent  on  digestive  disorder, 
43 
Cardiac  weakness,  252 
Cardialgia,  163 
Catalepsy,  27,  90,  215,  221,  222 

in  melancholia,  223 

table,  223 

transient,  181 
Cataleptoid  state,  114,  221,  222 
Catarrh,  symptomatic  uterine,  3 
Catarrhal  states,  4,  252,  279 
Causative  factors  in  reflex  disturb- 
ances, 4 
Cerebral  ansemia,  239 

excitement,  238 

hypertemia,  239 

irritations,  10 

neuroses,  10,  27 
Cerebro-abdominal  neuroses,  99 
Cerebro-spinal  nerves,  17 
Cerumen,  impacted,  4 
Cervical  induration,  90 

spine,  37 

sympathetic,  130 

tenderness,  37 
Charcot,  163,  184,  187,  190,  192,  197 
Change  of  climate,  60 
Cheyne-Stokes'  respiration,  85 
Chloasma,  98,  153 

uterinum,  151 
Chloasmata,  symptomatic,  150,  151 
Chlorosis,  90,  300 
Choking,  hysterical,  165 
Chorea,  general,  29,  165,  306,  314 

major,  242 

minor,  240 
Chromic  acid  in  hyperhidrosis,  127 
Cinchona  preparations,  298 
Cleanliness,  internal,  260 
Climacteric  changes,  74 
Coccygodynia,  113 
Cohn  on  uterus  and  eye,  132 
Cold,  327 

Coldness  of  extremities,  extreme,  50 
Colic,  99 

Collins  on  angeio-neurotic oedema, 78 
Colonic  flushings,  99 ' 
Condurango,  299 
Congestion  in  globus  hystericus,  11 


INDEX. 


359 


Constipation,  15,  108,  270,  308 

during  intermenstrual  period,  98 
during  menstruation,  98 

Constitution,  run  down,  2 

Contracted  chest,  252 

Contractures,  159,  196 
causes  of,  17-4 
general,  168 
treatment,  168 

Convulsions    with    dysmenorrhoea, 
220 

"  Convulsionaires,"  236 

Copious  water  drinking,  254 

Corpulence,  287 

Cough,  hysterical,  166 

Cramp  in  the  head,  247 

Cramps,  muscular,  8 

Cranial  cavity,  irritations  in,  20 

Dana,  243 

Debility,  evidences  of,  107 
Delirium  of  hysteria,  179 
Delusions,  fixed,  27 
Denis,  254 
Deprat,  171 

Dermal  reflex  neuroses  or  derma- 
toses, 149 
Dermatologist,  6 
Dermato-neurosis,  menstrual,  153 

treatment,  155 
Dermatoses,  12,  50,  98 

acne  rosacea,  153 

chronic  urticaria,  150 

reflex,  79 
Diabetes,  vasomotor  disorder  in,  64 
Diagnosis  of  disease,  5 
Diaphragm,  irritation  of,  40 
Diarrhoea  after  menstrual  period,  98 

preceding  menstrual  period,  98 

reflex  or  nervous,  5,  27,  100 
Diet  of  neurotic  patients,  272 
Dietetic  treatment,  271 
Digestive  disease,  6 

disorder,  a   common  symptom 
of,  82 

disorders  at  menopause,  8 

disturbances    in     cardiac   neu- 
roses, 45 

organs,  4 
Dilatation    of  uterine    cervix,    for 

stenosis,  318 


Dimness  of  vision,  128 
Diruf.  257 

Disease  mimicry,  147,  181 
Diseases,  organic,  of  nervous   sys- 
tem, 12 
Disturbances  of  vision,  129 
Donovan's  solution,  156 
Drowsiness  during  the  daytime,  27 
Dubois  (d'Amiens),  189 
Duncan,  319 
Dyschromatopsia,  197 
Dysmenorrhcea,  119,  153,  231 
Dyspepsia.  33 
Dyspnoea,  39,  85,  165 
Dysuria,  37,  109 

Ears,  4 

Ebstein  on  unilateral  hyperhidrosis, 
124 

Ecchymoses,  151 

Echeverria,  83 

Ecstasy,  216,  236 

Eczema  facialis,  150 

Edebohls    on    menstrual  dermato- 
neurosis,  153 

Electrotherapy,  253,  317 

Elimination   of  diseased   products, 
277 

EUinger,  320 

Emmet,  326 

Endocervicitis,  230 

Endometritis,  233 

a  causative  factor,  9,  71,  89,  90, 

154 
hepatic  obstruction  in,  91 

Engelmann,  5,  93,  186 

Enteralgia,  99,  163 

Enuresis,  27,  110 

Epigastric  swelling,  90 

Ephidrosis,  121 

Epilepsy,  12 

Errors  of  refraction  and  accommo- 
dation, 4 

Eructations,  hysterical.  166 

Eruptions  at  puberty,  150 
at  the  menopause,  150 
of  the  face,  155 

Ei'ysipelas,  "chronic,"'  49 

Ether,  304 

Excessive  perspirations,  49 

Exclusivism  in  medical  practice,  7 


360 


INDEX. 


Excretion  of  urea,  254 
Exophthalmic  goitre,  680 
Expectant  attention,  27 
External  hydrotlierapy,  253 
Eye  strain,  3,  4 

Faintness,  89 

False  croup,  306 

Fatalistic  standpoint,  253 

Faucheron,  244 

Fear,  a  factor  in  disease,  251 

Ferber,  256 

Fermentation  products,  260 

Fever,  hysterical,  179 

Flatulence,  98,  153,  317 

Flushing,  unilateral,  64,  65 

Food  accessories,  295 

Fowler's  solution,  156,  299 

Fi'aenkel  on  dyspnoea  and  hyperhi- 

drosis,  122 
Fried  meats,  153,  273 
Functional  disease,  6,  182 
paralysis,  30 


Gaube  on  hysterogenic  zones,  199 
General  medicine,  9 

practitioner,  2,  3,  10, 
Genital  and    digestive  organs  inti- 
mately connected,  11 

reflex  neuroses,  112 

weakness,  anaemia  present,  8 
Genito-urinary  organs,  4 

disturbance,  112 
Gilles  de  la  Tourette,  163 
Glandular  reflex  neuroses,  118 
Globus  hystericus,  6,  11,  27,  90,  119 
Glossitis,  superficial  forms,  141 
Glycogenic  functions  of  the  liver,  121 
Gritfin  Brothers,  36 
Gross  on  anachlorhydria,  91,  92 

on  cerebro-abdominal  neurosis, 
99 
Gynecologist,  6,  151 

surgical,  3 
Gynecologist's  range  of  vision,  9 

knowledge   of   digestive    disor- 
ders, 11 


Galvanism,  85 
Gamgee,  201 

Ganglionic  nerves,  irritation  trans- 
mitted through,  9 

nerves  observations  on,  36 

system,  48 
Gaseous  eructations,  107 
Gasserian  ganglion,  142 
Gastralgia  at  menstruation,  93,  212 

in  cases  of  retroversion,  8 
Gastric  catarrh,  5 

disturbance,   frontal    headache 
in,  91 

disturbance,  uterine  symptoms 
of,  91 

irritation,  15 

neuroses  of  pregnancy,  93 

neuroses,  persistence  of,  93 
Gastric  reflex  indigestion,  89 
Gastric  reflex  neuroses,  89 

common,  89 
Gastrodynia,  hysterical,  308 
Gastro-enteric  catarrh,  93 
Gastro-hystero-neuroses,  90 
Gastro-intestinal  catarrh,  results  of, 
49 

tract,  irritations  in,  11 


Haemorrhoids,  4,  108 
Hallucinations,  113,  139 
Hamilton,  185 
Hanks,  325 
Hart,  Ernest,  201 
Hart  and  Barbour,  185 
Hartraann,  unilateral  hyperhidro- 

sis,  125 
Haut  mal,  220 
Haziness  of  vision,  130 
Headache,  247 

bilious,  16 

congestive  reflex,  6,  10,  12,  247 

hypergemic,  247 

migrainous,  95,  315 

occipital,  95 
Heaviness  and  soreness  of  upper  ex- 
tremities, 40 
Heitzmann,  262 
Hemiplegia,  hysterical,  166 
Hemidrosis,  122 

Hemeralopia  (night  blindness),  128 
Heraiansesthesia,  11,  165 
Hemicrania,  13,  243 

anaemic  type,  51 

a  vasomotor  neurosis,  51 

from  ovarian  irritation,  51 


INDEX. 


861 


Hemicrania,  hypersemic  type,  51 
Hemorrhagic  spots,  151 

perspirations,  151 
Hepatic  stimulation,  99 

obstruction,  109 
Hereditary  nervous  weakness,  59 

diet  and  regimen  in,  59 

educational  treatment  in,  59 

massage  in,  59 

predisposition,  253 
Herpes,  150 
Hiccough  a  respiratory  neurosis,  85 

causes  of,  86 

hysterical,  166 

treatment,  86 
Highest  art  of  the  physician,  253 
Hilton  on  hysterical  pain,  145 
Hodge,  7 

Hoffman's  anodyne,  304 
Hot  applications  to  spine,  40 

baths,  261 

flushes,  73 
Hutchinson   on  unilateral  myosis, 

131 
Hydrsemia,  treatment  of,  40 
Hydrocephalus,  130 
Hydrotherapy,  40,  115,  167 
Hygiene,  253 
Hygienic  exercises,  85 
Hypersesthesia,  165,  197 

of  all  the  special  senses,  139 
Hyperhidrosis,  unilateral,  121 
Hypersecretion   of  salivaiy  glands, 

119 
Hypersensitiveness  of  nervous  sys- 
tem, 5 
Hypnotism,  27,  187 
Hypochondriacal  patients,  41 
Hypogastric  neuroses,  112 

plexus,  22 
Hysteria,  157 

age,  159 

anaemia  in,  158 

antesthesia,  161 

characteristics,  160 

climate,  159 

contracture,  161 

diagnosis,  161 

due  to  constitutional  weakness, 
158 

hemianaesthesia,  161 


Hysteria,  hemicrania,  162 

hereditary  taint,  158 

hypersesthesia,  162 

impaired  digestion  158 

insanity,  159 

major,  190 

morbid  fancies,  159 

neuralgias,  162 

occurs  in  epidemics,  158 

sedentary  occupations,  159 

sensory  disturbance,  161 

treatment,  181 
Hysteric  suffocation,  94 
Hysterical  aura,  197,  198 

contractures,  173 

convulsions,  167,  169,  181 

fever,  179 

gastrodynia,  308 

joint,  144 

psychoses,  179 

salivation,  179 

somnambulism,  180 

somnolence,  181 

stigmata,  167 

strabismus,  128 

trance,  181 

trismus,  90 

vasomotor  manifestation,  62 

yawnings,  194 
Hystero- catalepsy,  216 
Hystero-epilepsy,  183 

according  to   Charcot  and  Ri- 
cher, 183 

attacks  of  catalepsy,  190 

attacks  of  lethargy,  190 

attacks  of  somnambulism,  190 

contortions,  203 

demoniacal  attack,  203 

disorders  of  circulation,  194 

disorders  of  digestive  function, 
193 

disorders  of  motility,  196 

disorders  of  respiration,  194 

disorders  of  secretion,  194 

disorders  of  sensation,  196 

dysmenorrhosa     a     common 
cause  of,  217 

emotional  attitudes,  203 

exalted  emotions,  191 

hallucinations,  191 

hemiansesthesia,  196 


362 


IXDEX. 


Hystero-epilipsy,  opisthotonic  posi- 
tion, 218 

period  of  delirium,  213 

prodromic  period,  190 

sorrowful    hallucinations,    207, 
208 

tables  of,  205,  206 

with  combined  crises,  189 

.with  distinct  crises,  189 
Hystero-epileptic  attack,  184 
Hysterogenetic  zones,  199 
Hystero-neuroses,  8,  112 

ophthalmic,  216 

Iconographie  de  la  Salpetriere,  163 
Idiopathic  cedema,  79 
Idiosyncrasy,  275 
Impaction  of  colon,  98 
Incipient  renal  disease,  129 
Indigestion,  4,  6,  50 
Induration  of  cervix,  90 
Inflammatory  exudates,  260 
Insanity,  159,  314 

hysterical,  28 
Insomnia,  39,  270,  286 
Insufficient  or  improper  diet,  139 
Internal  hydrotherapy,  253,  260 

or  tissue  asepsis,  253,  260 

sterilization,  253,  260 
Intestinal  catarrh,  4 

glands,  hypersecretion  of,  98 
Introspection,  constant,  270 
Irritability,  excessive,  27 
Irritations,  peripheral,  3 

of  cord,  22 

of  ovary,  22 
Iron,  302 
Isolation,  237 

Joint  ankylosis,  144 

neuroses,  27 

pains,  27,  144 

stiffness,  144 

weakness,  144,  147 
Joints  and  ganglia  of  sympathetic, 
148 

and  ovarian  irritations,  147 

and  spinal  nerves,  148 

and  uterus,  147 

Kaempf  on  cervical  sympathetic,  131 


Keating,  62 

Keen  on  cervical  sympathetic,  131 

Kidneys,  4 

granular,  107 

irritability,  106 

neuralgic  pains,  106 

secretion,  106 

under   control  of  sympathetic, 
121 
Klebs,  263 
Koch,  258 
Kretol,  emulsion  of,  156 

Lacerated  cervix,  3,  234 

cervix,  reflex  neuroses  depend- 
ent on,  9,  144 
Lactation  and  affections  of  the  eye, 

133 
Lameness,  a  psychosis,  144 
Lai'yngeal  reflex  neuroses,  81 
Laryngismus,  hysterical,  27 

stridulus,  82 
Laryngitis  of  reflex  origin,  81 
Laryngologist,  12 
La  Tourette.  163 
Laughter,  hysterical,  166 
Lee,  185 
Lehman,  255 
Leichtenstern,  253,  254 
Leonard  on  female  voice  in  sexual 

disease,  83 
Lesions  in  lung  a  cause  of  reflex 

pain,  17 
Leszynsky,  309 
Lethargy,  113,  221 

complicated  by  contractions  or 

by  cataleptoid  state,  221 
intense,  27 
simple,  221 

with  apparent  death,  221 
Lichen,  150 
Liebreich,  201 
Lingual  neuralgia,  140 

local  applications  in,  140 
Lithferaic  conditions,  16 
Liver,  affections  of,  38 
Lobelia  in  nervous  asthma,  316 
Louyer  Villermay,  189 
Lumbar  ganglia,  22 

plexus.  17 
Lumbo-abdominal  neuralgias,  22 


INDEX. 


363 


Malapert,  174 
Malassimilation,  13,  235 
Mallendorf,  244 
Mammary  glands,  118 

changes  in,  118 

pain,  118,  153 

swelling,  118 
Mania,  27 

chronic,  12 
Zvlarsh,  146 

Massage,  169,  182,  261,  288 
Mastodynia,  remedial  measures  in, 

118 
Mechanical  purification,  260 
Medicinal  treatment,  297 
Melancholia,  27,  94,  229,  300,  305 
Memory,  loss  of,  27 
Menopause,  43,  45 

vasomotor  neuroses  of,  74 
Menorrhagia,  232 

Menstrual  congestion,  morbid  appe- 
tite at,  91 

hystero-neuroses,  8 
Menstruation,  83 

gastric  changes  during,  91 

cedema  preceding,  77 

sudden  suppression  of,  90 

vicarioixs,  77 
Mental  depression,  27,  139,  211 

disturbances,  vasomotor  change 
in,  50 

influences  in  cardiac  neuroses, 
45 
Metabolism,  253 
Micro-organisms,  259 
Migraine,  12,  29,  234,  243,  328 

congestive  type,  305 

production  of,  14 

treatment  of,  245 
Mills,  184,  186 

Mitchell,  62,  130,  167,  168,  181,  184, 
288 

on  cervical  sympathetic,  130 

on  hysteria,  167 

on  hysterical  contractures,  167 

on  treatment,  283 
Morbid  appetites,  cravings,  91,  96 

fears,  27 

flushing  at  menopause,  48,  306 

flushing  a  vasomotor  paralysis, 
50 


Morbid  flushing,  chronic  gastro-in- 
testinal  catarrh  in,  49 

flushing,  inherited,  55 

flushing  or  blushing,  48 

flushing,  salivation  in,  49 

flushing,  treatment,  61 

growths,  4 
Morehouse,  131 
Molimen  menstruale,  155 
Motor  disturbances,  migratory,  40 
Mouches  volantes,  128,  130 
Miiller,  319 
Murray,  on  anidrosis,  127 

on  bromidrosis,  126 

on  hyperhidrosis,  126 
Murray's  treatment,  126 
Muscular  exercises,  264  ' 
Mydriasis,  128,  130 

ephemeral,  136 

functional,  135  ' 

Myosis,  121,  128,  130,  132 

Narcolepsy,  113 
Narcotics,  306 
Xasse,  254 
Nausea,  95 

and  vomiting,  39 
Nebel,  241 
Nervous  disorders,  3 

exhaustion,  27 

prostration,  41,  106 

system,  disturbance  of,  2 
Neuralgia,  inflammatory  local,  7 
Neuralgias,  306 

cardiac,  14 

digital,  16 

during  pregnancy,  140 

intercostal,  14 

in  the  heel  and  wrist,  16 

lingual,  140 

migratoiy,  40  ■ 

transferred  or  reflex,  14 
Neurasthenia,  27 

anachlorhydria  in,  91 
Neurasthenic  conditions,  16 

patients,  45 
Neurologist,  6 
Neuroses,  classification,  13 

combined,  13 

common.  13 

definition,  2 


364 


IJSTDEX, 


Neuroses,  general  or  local,  2 

of  menstrual  period,  90 

reflex,  1,  2 
Niemeyer,  256 

Night  blindness  (hemeralopia),  128 
Non-bacteriological  affections,  252 
New  growths.  4 
Nyctalopia  (day  blindness),  128 

Obesity,  289 

Ocular  tenotomy,  enthusiast  in,  2 

Oculist,  6 

Oculo-pupillary  disorders,  130 

O'Dwyer,  327 

CEdema,  acute  idiopathic,  79 

angeio-neurotic,  77 

circumscribed,  79 

indefinite  duration,  78 

lympathics  in,  77 

non-inflammatoi-y,  79 

veins  in,  77 
CEdema,  hysterical,  80 

varieties,  80 
Oophorectomy  for  hystero-epilepsy, 

186 
Oophoritis,  230 
Ophthalmic  reflex  neuroses,  128 

symptoms,  128 
Opiates,  306 

Opium  and  valerian.  306 
Organic  or  structural  disease,  6 
Orgasms,  116 

treatment,  116 
Out-of-door  exercise,  60 
Ovarian  hypersesthesia,  210 

irritation,  114 

neuralgia,  306 

pain,  119 
Ovary,  cystic,  3 
Overexertion,  253 
Oxalate-of-lime  crystals  in  urine,  106 

Paget,  146 

Pain  at  the  hip  joint,  144 

frontal  or  temporal,  14 

gall  bladder,  16 

in  abscess  of  spleen,  16 

in  the  knee,  144 

in  the  wrist  or  ankle,  144 

kidney, 15 

occipital,  15 


Pain,  scapular  or  shoulder,  15 

transferred,  15,  17 
Pallor  of  face,  exti'eme,  50 
Palmer,  320 

Palpitation  of  the  heart,  39 
Palsy,  facial,  31 
Pancreatic  digestion,  297 
Paralysis,  ansemic,  31,  32 

complete,  31 

crutch,  31 

functional,  30 

hysterical,  30 

organic,  32 

partial,  31 

vesical,  31 
Paraplegia,  11,  31,  32 
Parasites  in  milk,  279 
Parotid    glands    and    reproductive 

organs,  119 
Parotiditis  and  oophoritis,  120 
Passions  of  the  mind,  252 
Peaslee,  323 
Pelvic  cellulitis,  6 

irritations,  17 
Period  of  delirum,  213 
Periodic  swelling,  79 
Peripheral  irritation,  3 
Perspirations,    excessive,  of  hands 
and  feet,  120 

localized,  124 

malodorous,  120 
Phagocytosis.  259 
Pharyngeal  inflammation,  12 

reflex  neuroses,  81 
Pharyngitis,  chronic,  from    imper- 
fect digestion,  82 

of  reflex  origin,  81 
Photophobia,  130 
Phthisis,  259 

intercostal  neuralgia  in,  17 
Physical  exercise,  265 
Physicians,  practical,  1 

scientific,  1 
Pigmentation,  153 
Pneumogastric  nerve,  22 
Podalgias,  22 
Polyuria,  107,  108 
Portal  circulation,  90  - 
Post-nasal  catarrh,  50 
Practitioner,  general,  2 
Pregnancy  and  visual  apparatus, 133 


INDEX. 


365 


Preparation  of  meat,  274 
Prophylaxis,  252,  253 

modern,  252 
Proteids,  273 
Prurigo,  150 
Pruritus,  150 

ani,  3 
Pseudo-angina  pectoris,  42,  45,  107 

treatment  of,  43 
Psychological  treatment,  129 
Psychoses  or  cerebral  neuroses,  27, 

28,  300 
Ptosis  a  reflex  from  gastric  or  hepat- 
ic disease,  129 
Puerperal  amaurosis,  129 

mania,  28 

melancholia,  28 
Puerperium  and  eye  affections,  133 
Pulmonary  disease,  5 
Pulse,  75 

Quinine  sulphate,  299 

Reconstructive  remedies,  297 

Rectum,  4 

Reflex  asthma,  306 

conditions,  6 

coughs,  306 

disturbance,  4 
Reflex    dermatoses    dependent    on 
menstrual  disturbance,  151 

hystero-neuroses,  5 

pains  are  transferred  pains,  14 

pains  from  viscera,  22 

vasomotor  changes,  14 
Reflex  neuroses,  1 

congestion  in,  11 

differential  diagnosis,  11 

symptoms  in,  10 
Renal  reflex  neuroses,  106 

hypersecretion,  106 

irritability,  106 

nervous  prostration  in,  106 

secretions,  106 
Rendu  on  unilateral  mydriasis,  132 
Retinal  anaesthesia,  128 

hypereesthesia,  128 
Retroflexion,  233 
Rhinitis,  chronic,  82 
Rhinologist,  12 
Richer,  164,  170,  173,  176,  190,  196 


Rockwell  on  unilateral  hyperhidro- 

sis,  124 
Rosenthal  on  unilateral  mydriasis, 

131,  132 
Routine  practice,  252 

Salivation,  308 
Salpetriere,  176 
Sandras,  189 
Sayre,  171 
Schmidt,  255 
Schroeder,  318 
Sciatica,  22,  132 
Scientific  physicians,  1 

problems,  1 
Scrofulous  diathesis,  107 
Seasickness,  treatment  of,  305 
Seborrhcea,  152 
Seeligmiiller  on  atrophy  of  cheek, 

131 
Sensation,    reflex,    disturbances  of, 

in  lower  extremities,  8 
Seguin  on  unilateral  hyperhidrosisi 

122 
Sexual  apparatus,  118 

orgasms,  recurrent,  114 
Shouting,  hysterical,  166 
Simulated  disease,  36 
Simulation  of  disease,  2 
Simpson,  305,  319 
Sims,  320,  323 
Sneezing,  reflex,  86 
Solar  plexus,  35 
SoUier,  174 
Somnambulism,  270 

hysterical,  180,  211,  215 
Souques,  179 
Spasm,  hysterical,  165,  168 

muscular,  15 

of  bladder,  16 

of  larynx,  165  ■ 

of  cesophagus,  165 

of  pharynx,  165,  194 

of  sterno-cleido-mastoid,  165 

of  trapezius,  165 
Special  feeding,  289 

treatment,  251 
Specialist,  2,  3 
Spinal  irritation,  34,  38,  233 

ansemic  form,  41 

hypersemic  form,  39 


366 


INDEX. 


Spinal  irritation,  treatment,  41 

inflammation,  38 

pains,  34 

reflex  neuroses,  34 

system,  5 

tenderness,  37,  157 
Splanchnic  nerve,  35 
Spurious  peritonitis,  187,  197 
Squint,  hysterical,   165 
Stammering,  140 
Stenosis  case,  327 
Strabismus,  hysterical,  128,  165 
Strengthening  treatment,  251 
Suffocation,  hysterical,  27,  94 
Surgeon, 6 

Sydenham's  chorea,  168 
Sympathetic  ganglia,  20,  21 

pains,  34 

system,  5 
Sympathy  for  minor  ailments,  2 
Symptomatic  chloasmata,  150,  151 

treatment,  252 
Symptonft,  abdominal,  2 

uterine,  2 
Systematic    constitutional    treat- 
ment,  253 

Tachycardia,  176 

Therapeutics,  251 

Thomson,  328 

Thread-worms,  4 

Thyroid,  swollen,  6,  119 

Tilt,  7 

Tissot,  189 

Todd  on  hysterical  hemiplegia,  166 

Trance,  27,  113,  221,  et  seq. 

table,  223 
Trismus,  hysterical,  90 
Tropho-neuroses,  80 
Tubercle  bacillus,  259 
Tuberculosis,  258 
Tumefaction,  153 
Turner,  201 
Tympanites,  90,  194 

Unhygienic  living,  50 
Unilateral  sweating,  123 
Urination,  difficult,  108 

effect  of  fear  or  fright  on,  106 

frequent,  108 

incontinence,  108 


Urination,  pain  after,  108 
painful,  108 
retention,  108 
Urine,  hyperacid,  108 
nervous,  194 
pale,  107 
Urticaria,  80,  150 
giant,  79 
tuberosa,  79 
Uterine  disease,  152 

a  cause  of  insanity,  7 
gastric   neurosis    most    fre- 
quent in,  92 
disorders  at  menopause,  8 
examination  of  unmarried,  10 
involution,  29 
neuralgia,  96,  308 
neuroses,  92 
pain,  119 
Uterus  and  eye,  182 

growth  and  activity  of,  during 
pregnancy  a  cause  of  reflex 
neuroses,  88 

Vascular  reflex  neuroses,  47 
burnings  of  the  palms,  47 
burnings  of  the  side  of  the  chest, 

48 
burnings  of  the  soles  of  the  feet, 

47 
burnings  of  the  top  of  the  head, 

47 
coldness  of  extremities,  48 
erythematous  eruptions,  48 
external  or  internal,  47 
flushes,  47 
flushing  of  malar  prominences, 

47 
general  or  local,  47 
general  or  nervous  chills,  47 
hemorrhages,  48 
of  puerperal  circulation,  47 
sweats,  48 
Vasomotor  disorder,  functional,  64, 

101 
ganglia,  68 
nerves,  65,  66,  67,  68 
neuroses  of  pelvic  origin,  65 
spasmodic  varieties,  70,  72, 
73 
paresis  of  lower  extremities,  62 


INDEX. 


367 


Vegetable  diet,  278 

foods,  294 
Vertigo,  39 
Vesical  reflex  neuroses,  108 

causes  of,  108 

varieties,  108 
Virchow,  201 
Vitality,  253 

lowered,  5 

in  patients,  44 
Voice,   changes  in,  at  the  time   of 

menstruation,  83 
Voit,  256 

Voluntary  blushing,  57 
Vomiting,  reflex,  305,  808 

nausea  and,  39 

violent,  8,  95 

Wakefulness,  27 


Wallet,  178 

Water,  internal  use  of,  253 

Watson,  241 

Weeping,  hysterical,  94, 166 

Weyrich,  256 

Wilson,  on  hyperhidrosis,  125 

Wines,  generous,  298.  300 

Woman,  functional  derangements,  1 

physical  discomforts,  1 
Women,  neuroses  of,  3 
Worry  and  anxiety,  269 

Yawning,  a  trivial  neurosis,  86 
causes  of,  86 
hysterical,  166 

Zander,  251,  264,  268 
Ziemssen,  253 


W\l 


